guyerwellnessgroup.com - INTAKE FORM

Tell Us a Little About You
What is your name?*

First NameLast Name
What is your date of birth?*

MonthDayYear
Date
What is your phone number?
Please enter a valid phone number.
What is your email address?*
example@example.com
In what state do you reside?*
What is your current weight?
How tall are you?
What is your weight loss goal?

It’s our goal to help you get to your desired weight and lose pounds!
Have you previously struggled to lose weight?

YesNo

Do you feel that you have control over your eating habits?

NeverRarelySometimesFrequently

Do you have any of these?

High Blood PressureHigh Blood pressure medicationHigh CholesterolHigh HomocysteineOther weight issuesNone of these

Have you ever taken these peptides? If Yes, which ones?

SemaglutideCJC1295IpamorelinTirzepatideNone of these

Have you taken any of these?

OzembicWagoviaNone of these

Please list all supplements and medications you are taking.

THANK YOU FOR PROVIDING THIS INFORMATION. IT WILL HELP US TO HELP YOU SUCCED IN REACHING YOUR GOALS.

Is there anything else you can share that will enable us to provide you with top-notch care?

We recommend a healthy lifestyle and an exercise program to enhance your treatment, using semaglutide.

If you have other physicians providing your care, please discuss the use of this peptide with them as well.

I have read and understand the therapy and responsibilities.

Semaglutide is a peptide and it is quite effective and works efficiently for weight loss. You agree to receive this treatment from just one provider at a time and we will give you detailed instructions about the use and care of this treatment.

Accept this consult and the Terms and Conditions.

Please upload a photo ID, in order to participate in this treatment.

Cancelof
Should be Empty: