Patient Intake

Let's get started by understanding your current weight loss goals: *

Lose 1-20lbs for good
Lose 21-50lbs for good
Lose over 50 for good
Maintain my health weight
Other

Maybe weight loss isn't your #1 goal? Tell us more about what you are hoping to accomplish in the program:

Which weight loss methods have you tried in the past? *

Exercise
Dieting
Weight-Loss Supplements
Intermittent Fasting
GLP-1 Medication
None of the Above

(select all that apply)

Height *

Weight (In Pounds) *

BMI:

What is your age? *

Which GLP-1 medication are you interested in? *

Are you currently taking GLP-1 medications? *

GREAT, so you are already somewhat familiar!

Which GLP-1 medication are you currently taking? *

Please upload proof of your current prescription:

Choose file or drag here

Supported format: JPG, JPEG, PNG, GIF, SVG.

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Do you have any of the following conditions? *

Medullary Thyroid Cancer (MTC) or family history of MTC or Multiple endocrine neoplasia Type 2 or any cancer
Multiple Endocrine Neoplasia Syndrome Type 2 (MEN 2)
Serious Allergic reaction to Semaglutide or Tirzepitide or compounded components
Active Cancer
Active Drug or Alcohol Misuse
Eating disorders
Bipolar Disorder
Schizophrenia
Pancreatitis
Diabetes mellitus type 1
Any liver or Kidney disease
Active gallbladder disease
Chronic or persistent hypoglycemia with ranges < 60 mg/dl
Pregnant or planning to become pregnant in the next 2 months
None of the above

(select all that apply)

Do you have any of the following conditions? *

High Cholesterol
High Blood Pressure
Pre-Diabetes
Type 2 Diabetes
Fatty Liver Disease
None of the Above

(select all that apply)

Are you currently taking any medications? *

Please list the medications and doses you are currently taking:

Do you have any known allergies? *

Please list all known allergies here:

Please select your provider from the list below: *

Which type of consultation would you prefer?

There are a few options! We all know about VIDEO and PHONE consultations so there isn't much to explain there. Did you know there's also a third option called an ASYNCHRONOUS consultation?!

Asynchronous consultations are the quickest way to get approved for your new medication. Our providers will review the information you submitted and message you directly if they need further details. If they have all the information they need for your prescription, they will make a decision on the spot without the need for a video or phone consultation. Fingers crossed for an approval!

Please select the type of consultation you would like to proceed with: *

Please upload a valid government issued form of ID (Driver's License, Passport, etc.): *

Choose file or drag here

Supported format: JPG, JPEG, PNG, GIF, PDF, DOCX.

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First Name *

Last Name *

Gender *

Email *

Password *

Phone *

Date of Birth *

Stripe Setup ID

Submit

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get in touch with you soon!

If you selected video or phone consultation, please book your appointment by clicking the link below.

https://calendly.com/koa-life

Have a great day!

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get in touch with you soon!

If you selected video or phone consultation, please book your appointment by clicking the link below.

https://calendly.com/koa-life

Have a great day!

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