Contact Us

Medical Questionnaire Intake Form

Complete a short, 2-minute health questionnaire to get prequalified for a doctor's consultation and start your journey to a healthier you!

Please be sure to fully fill out each and every field. Paying careful attention on payment page, to use the same email and telephone number as used on the Intake form.)

Patient's First Name *

Patient's Last Name *

Patient's Phone *

Patient's Email *

Date of birth *

What's your height: Feet? (Enter inches on next slide) *

Inches *

What is your current weight? *

Have you gained weight in the last 2 years? *

How much weight did you gain?

Target Weight *

Did you experience weight issues as a child? *

Do you have a personal history of diabetes? *

Do you have a history of hypertension (HCN)? *

Do you have a history of high cholesterol? *

Please list all previous weight loss prescriptions you have taken. *

Please list all current prescriptions, medication names and dosages. *

Any known allergies to any medications? List all. *

Have you had a gastric bypass? *

Have you had a Gastric Band? *

Do you have a history of Pancreatitis? *

Do you have a history of Thyroid Cancer? *

Do you have a history of Multiple Neoplasia 1 or 2 (Cysts on the endocrine glands)? *

Sex Assigned At Birth (accuracy is important for medical/risk aversion precautions) *

Do you have a history of PCOS (Poly-cystic ovarian syndrome)? *

Is there a family history of (PCOS) Polycystic Ovary Syndrome - for women only *

Are you currently pregnant or breast-feeding or do you plan to become pregnant? *

Would you say your current level of daily exercise is sedentary, moderate, or high? *

Do you have a family history of diabetes? *

Do you have a family history of heart disease? *

Do you have a family history of obesity? *

Billing Address *(NOT SHIPPING ADDRESS) *

Billing City *(NOT SHIPPING CITY) *

Billing STATE *(NOT SHIPPING STATE) *

Billing Postal Code *(NOT SHIPPING POSTAL CODE) *

Is your billing address the same as your shipping address? *

How did you hear about us?

What do you do for a living?

Shipping Address:

"Required if not same as your billing address

Shipping City

"Required if not same as your billing city

Shipping State

"Required if not same as your billing state

Shipping Postal Code

"Required if not same as your billing postal code

Is patient paying with a credit/debit card in his/her own name? *

Cardholder First Name *

Cardholder's Last Name *

If we need to contact your local pharmacy to prescribe supportive medication in case of nauseau we'll need your local pharmacy's name and contact information.

Street Address of your local pharmacy?

What's the name of your local pharmacy?

Phone Number of your local pharmacy?

By providing your phone number and clicking the box, you agree to the Terms and Conditions | Privacy Policy You also agree to receive automated SMS messages for commercial purposes from SkinnyLabCo. Message and data rates may apply. Message frequency varies. Reply Stop to Unsubscribe.

Processing of Doctor Review, Personal Consult &

Prescription Fee collection.

Use the same email and telephone number on the payment form as used on the Medical Intake form. Be sure to use Billing Zip Code when entering Credit/Debit Card information.

Telephone consultation includes review of medical information, phone call with the doctor, and the prescription approval. If denied then the $119 is refunded. The call takes less than 5 minutes and comes from a 719 area code.

Payment

[email protected]

312-900-3778

10152 HAILEY LYNNE ROAD, LAS VEGAS, NV, 89101

Contact Us

Medical Questionnaire Intake Form

Complete a short, 2-minute health questionnaire to get prequalified for a doctor's consultation and start your journey to a healthier you!

Use the same email and telephone number on the payment form as used on the Medical Intake form. Be sure to use Billing Zip Code when entering Credit/Debit Card information.

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