Assessment for Weight Loss

Weight Loss

Please fill out the form below so that our clinicians can determine if the treatment will be suitable for you to take.

1 Acknowledgement

These questions are designed to help us understand how you will use the medication we may prescribe for you.

Please Note: If this is your first time taking this medication, you will only be allowed to order the initial strength for Mounjaro (2.5mg) and Wegovy (0.25mg). Following the initial dose, subsequent orders will be increased in strength using a stepwise approach.

2 Your Health

These questions help us understand who you are and your current health.

Only images are accepted.
Weight
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