Weight Loss Medication Screening Form

Comments

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

First Name:*

Last Name:*

Your Email:*

Date of Birth*

Our maximum age for weight loss medications is 70.

Cell Phone:*

Height (ft):*

Please enter a number from 4 to 7.

(for example for 5' 2", enter 5)

Inches:*

Please enter a number from 0 to 11.9.

(for example for 5' 2", enter 2)

Weight (lbs):*

Please enter a number from 100 to 1000.

BMI:

Preferred Appointment Location:*

First appointment must be in-person!

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