Patient Intake Form

What is your current height?(Required)

What is your current weight?(Required)

What is your target weight or weight loss goal?(Required)

What is your primary goal for seeking weight loss treatment?(Required)

How motivated are you to follow a long-term weight management plan?(Required)

Very Motivated

Somewhat Motivated

Neutral

Not Motivated

How long have you been experiencing weight-related health challenges?

Have you noticed significant weight changes recently (gain or loss)?(Required)

Yes

No

Do you have any dietary restrictions, allergies, or follow any specific dietary patterns (e.g., vegetarian, keto, intermittent fasting)?

Do you engage in regular physical activity? How often?(Required)

How many servings of fruits and vegetables do you consume daily?

Please enter a number from 1 to 1000.

Do you have any concerns about taking weight loss medication?(Required)

Have you previously used any weight loss medications or supplements?(Required)

Yes

No

Have you previously used GLP-1 medications (semaglutide, tirzepatide, Mounjaro, Wegovy, Zepbound, Ozempic, Rybelsus)?(Required)

Yes

No

Have you ever experienced significant side effects from weight loss medications?(Required)

If you have a history of an eating disorder, was it:

Disclaimer & Consent

I confirm that all my answers are accurate and complete.

Do you consent to this information being reviewed by a licensed medical professional to determine your eligibility for care?

I authorize Dr. Laura Bennnett and staff to help me in my health and wellness efforts. I understand that my program may consist of behavioral modifications, supplements, nutraceuticals and/or medications including, but not limited to, those for weight loss, skin care, hair regrowth, longevity or other medications that are sourced from 503A or 503B pharmacies that are under the oversight of state Boards of Pharmacy or the FDA.

I understand that any medical treatment may involve risks as well as proposed benefits. I also understand that there are certain health risks associated with an unhealthy lifestyle, including but not limited to cancer, high blood pressure, diabetes, heart attack and heart disease, arthritis of the joints including hips, knees, feet and back, sleep apnea, and sudden death.

I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances made to me that the program will be successful.

Name

First Last

Email

Phone

Patient Consent(Required)

I confirm that all my answers are accurate and complete.

I consent to this information being reviewed by a licensed medical professional.

I authorize Dr. Laura Bennett and staff to assist me with my health and wellness program.

I understand that results are not guaranteed and treatment carries risks.

Phone

This field is for validation purposes and should be left unchanged.