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Patient's First Name *

Patient's Last Name *

Patient's Phone *

Patient's Email *

Date of birth *

Please confirm your sex assigned at birth: *

What's your height: Feet? (Enter inches on next slide) *

Inches *

What is your current weight? *

Have you gained weight in the last 2 years? *

How much weight did you gain?

Target Weight *

Did you experience weight issues as a child? *

Do you have a personal history of diabetes? *

Do you have a history of hypertension (HCN)? *

Do you have a history of high cholesterol? *

Please list all previous weight loss prescriptions you have taken. *

Please list all current prescriptions, medication names and dosages. *

Any known allergies to any medications? List all. *

Have you had a gastric bypass? *

Have you had a Gastric Band? *

Have you had any other non-orthopedic surgeries? If so please list them all with the year of the surgery. *

Do you have a history of Pancreatitis? *

Do you have a history of Thyroid Cancer? *

Do you have a history of Multiple Neoplasia 1 or 2 (Cysts on the endocrine glands)? *

Sex Assigned At Birth (accuracy is important for medical/risk aversion precautions) *

Do you have a history of PCOS (Poly-cystic ovarian syndrome)? *

Is there a family history of (PCOS) Polycystic Ovary Syndrome - for women only *

Are you currently pregnant or breast-feeding or do you plan to become pregnant? *

Would you say your current level of daily exercise is sedentary, moderate, or high? *

Do you have a family history of diabetes? *

Do you have a family history of heart disease? *

Do you have a family history of obesity? *

Billing Address *(NOT SHIPPING ADDRESS) *

Billing City *(NOT SHIPPING CITY) *

Billing STATE *(NOT SHIPPING STATE) *

Billing Postal Code *(NOT SHIPPING POSTAL CODE) *

Is your billing address the same as your shipping address? *

Shipping Address: *

Shipping City *

Shipping State *

Shipping Postal Code *

Is patient paying with a credit/debit card in his/her own name? *

Cardholder First Name *

Cardholder's Last Name *

Please select the name of the advisor who helped you: *

Do you have a promo code? *

PROMO CODE

Please upload a copy of the front of your ID *

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1 In a clinical trial , the participants with BMI 30 or more, or 27 or more with at least one weight-related condition, the average participant lost 14.9% of body weight during the 68-week trial.

* California patients may encounter 2-day shipping.

*Important Notice: The recognized brand name medication approved by the FDA, Wegovy® & Ozempic®, is manufactured by Novo Nordisk™. We do NOT manufacture this medication and have no direct affiliation with Novo Nordisk™. Our partner pharmacies can supply Zepbound™ or Mounjaro® upon patient request, availability of brand name medication is dependent on supply.

Regarding compounded semaglutide, our company works with Sterile compounding pharmacies. These facilities undergo strict inspections, but because the compounded pharmaceuticals they produce are made according to a prescription from a specific practitioner for a particular patient, they are not FDA-approved. It might be challenging to directly compare the results and risk profiles of FDA-approved and compounded pharmaceuticals due to differences in strength, dose, and other factors. The medical judgment of a licensed clinician, based on a telemedicine interaction and medical history, determines the prescription of any compounded medication.

100% money back guarantee if your prescription is not approved; newhopeweightloss.net does not directly offer medical or pharmacy services. We partner with medical professionals who use HIPAA-compliant platforms to deliver services. This website’s content is meant only as a source of information; it should not be used as a substitute of expert medical advice, evaluation, or care. Please contact your doctor if you have any questions or concerns regarding your health.