Weight Loss Medication Screening Form

Your BMI is too low for initiation of treatment with weight loss medications. Kentucky requires a BMI over 25, and Ohio requires a BMI over 27.

Your BMI is too low for initiation of treatment with weight loss medications. Ohio requires a BMI over 30, or a BMI of 27-30 with weight-related medical conditions.

Your BMI is too low for initiation of treatment with weight loss medications. Kentucky requires a BMI over 27, or a BMI of 25-27 with weight-related medical conditions.

We require a minimum medication-free break of 3 months before re-starting treatment.

Patients who are pregnancy or nursing are not candidates for weight loss medications.

Please note that a controlled substance report will be reviewed prior to prescribing any medications. Any false or misleading statements regarding medical conditions, substance abuse history, or recent prescriptions for weight loss medications could result in a permanent ban based on Ohio and Kentucky regulations.

According to the State Medical Boards of Ohio and Kentucky, patients with a current (or past) history of any type of substance abuse disorder are not eligible for weight loss medications.

You may not be eligible for weight loss medications based on your medical history. Your information will be reviewed and a team member will be in contact with you.

You may not be eligible for weight loss medications based on your current medications. Your information will be reviewed and a team member will be in contact with you.