Medical Weight Loss Form

Please note, all fields are required. If a field does not pertain to you, please type "N/A" or "Not applicable".

ATTENTION- PLEASE READ THE NOTICE BELOW BEFORE CONTINUING!

Thank you for your interest in our Medical Weight Loss program. Because you have checked at least ONE of the situations or conditions above, this may not be the best time for you to be using the Semaglutide (medical weight loss) medication. Please do not continue filling out this form! Feel free to call Heather Garlinghouse, our Program Coordinator, at 605-217-5511 if you have any further questions about our Medical Weight Loss option.

Personal Info

Email*

Phone Number*

Date of Birth*

Medical Info

Height*

Weight*

Family Doctor*

Preferred Pharmacy*

Drug Allergies*

Other hospitalizations and medical problems: