Name * First Name Last Name Email * Date of Birth * MM DD YYYY Beginning Weight * This is the weight you started your journey Current Weight * This is the weight you just got from your scale What medication are you using? * Medication name Have you had any side effects? * How many units are you using? * What lifestyle changes are you making? * What changes are you making to sustain your weight loss? * Do you want to reorder medication? If no, please notify me at 317-873-5509 to reorder your medication or if you would like to stop your weight loss visits. Yes, order and charge my credit card on file. I understand to allow 7-10 Business days for delivery No, I do not want to order medication at this time. I will notify when medication is needed. I understand I should allow 7-10 Business days for delivery. Message (optional) Thank you! We will be in touch soon!
