Weight loss intake form (initial)

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Email *

Full Name *

Age *

Height *

Current Weight *

Desired Weight *

Have you ever had the following conditions? Check all that apply *

Thyroid cancer

Multiple Endocrine Neoplasia 2 MEN2(cancer)

Pancreatitis

Gallbladder disease

Substance use disorder (including alcohol)

Family history of thyroid cancer

Family history of Medullary Endocrine Neoplasia

None

Required

Please list any current medications you’re taking. *

Please check any of the following that apply to you: *

Currently pregnant or lactating

Planning to get pregnant within the next year

Not planning to get pregnant within the next year

Not applicable

Required

Have you tried GLP-1 like medications before (semaglutide/ozempic, tirzepatide/mounjaro, etc)? *

Please list any other questions or concerns regarding starting weight loss medication?

Please type your name below to acknowledge the following: I understand that Luxx Skinny Medical, LLC does not bill or accept insurance. Prior to scheduling a televisit with a Luxx Skinny Medical, LLC practitioner, I acknowledge that payment will be made in full for the first month of treatment which includes the televisit consult and appropriate dose of compounded medication. Please type your full name to acknowledge. *

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