Medical Weightloss Form

How to Complete Your Consultation Request

1. Fill Out the Form 
Please provide your details in the form to help us understand your needs and schedule your consultation.

2. Select Your Products 

Once you’ve submitted the form, you’ll be directed to choose the products you’d like to discuss during your consultation. This helps us prepare and ensure you get the best recommendations.

3. Schedule Confirmation 

Our team will review your submission and reach out within 24 to 48 hours to finalize your consultation details.

If you have any questions or need assistance, please contact us at (706) 692-9768.

We look forward to helping you!

Personal Information

Patient First Name

Please complete this field.

Patient Last Name

Please complete this field.

Date of Birth

Please complete this field.

Height

Please complete this field.

Current Weight

Please complete this field.

Phone Number

Please complete this field.

Street Address

Please complete this field.

City

Please complete this field.

State

Please complete this field.

Zip Code

Please complete this field.

Medical History

Do you have a personal or family history of medullary thyroid carcinoma (MTC)?

Please select an option.

Have you ever been diagnosed with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)?

Please select an option.

Have you ever had pancreatitis or any pancreatic disorders?

Please select an option.

Do you have a history of gallbladder disease (e.g., gallstones)?

Please select an option.

Do you have any history of kidney (renal) problems or currently have reduced kidney function?

Please select an option.

Have you been diagnosed with diabetes?

Please select an option.

Do you have a history of eating disorders (e.g., anorexia, bulimia)?

Please select an option.

Medication Use

Are you currently taking any diabetes medications (e.g., insulin, metformin, sulfonylureas)?

Please complete this field.

Are you currently taking any medications (prescription, over-the-counter, or supplements)?

Please complete this field.

Are you currently taking any weight loss medications (e.g., phentermine, bupropion, orlistat)?

Please complete this field.

Are you allergic to any medications or ingredients?

Please complete this field.

Lifestyle Assessment

On average, how many days per week do you engage in physical activity (30 minutes or more)?

Please complete this field.

How would you describe your current eating habits?

Please complete this field.

Are you pregnant, trying to conceive, or breastfeeding?

Please complete this field.

Goals & Expectations

What is your primary goal with weight loss therapy?

Please complete this field.

How much weight are you hoping to lose (in lbs or %)?

Please complete this field.

Have you previously tried weight loss programs or medications?

Please complete this field.

Do you have any specific concerns or questions about GLP medications (Semaglutide/Tirzepatide)?

Please complete this field.

Subscribe to updates from Prestige Medical Group