Weight Loss Intake Form - Wally Moon Telehealth

Congrats on taking the first step to weight loss with Wally Moon!
This questionnaire will provide our Doctors important information so they can assess your condition and prescribe medication if appropriate.
By clinking "START" below you consent Telehealth , Privacy Policy and Terms.

Please select your State: (We need to confirm that we are licensed in your state)(Required)

Unfortunately, we cannot service this condition in your state. Please contact your local physician for assistance.

Your state may require a phone or video consultation to complete your treatment. Don't worry!
Your doctor will reach out to you if this is the case.

What is your full name?(Required)

First Name Last Name

Please provide your email address:(Required)

Consent(Required)

By checking here you consent to future correspondence from Wally Moon at the email address you provided.(Required)

What is your gender?(Required)

Male

Female

Are you CURRENTLY taking any prescription medications for weight loss?(Required)

Yes

What is your date of birth? (Must be 18 years or older to qualify)(Required)

Please enter a qualifying date of birth.

What is your height and current weight?  (We use this information to calculate your BMI which helps determine treatment qualification)

Feet(Required)

Inches(Required)

Hidden

Height in Inches (Calculated)

Lbs(Required)

Hidden

BMI (Calculated)

Please enter the best contact phone number to reach you in case one of the doctors has any questions regarding your medical information.(Required)

Can we also send you text messages? (about your prescription, shipment tracking information, or refills)(Required)

Yes

Consent(Required)

By checking this box, I also consent by electronic signature to receive phone calls and/or SMS text messages at the phone number above, including my wireless number if provided. I understand these calls may be generated using an automated technology, pre-recorded voices and that data rates may apply. I understand that my consent is not required to buy goods/services and I may opt out at any time to avoid receiving calls or SMS messages.(Required)

Do any of the following conditions apply to you?(Required)

Currently or possibly pregnant, or actively trying to become pregnant

Breastfeeding or bottle-feeding with breastmilk

End-stage kidney disease (on or about to be on dialysis)

Type 1 or 2 diabetes

Current or prior eating disorder (anorexia/bulimia)

Current suicidal thoughts and/or prior suicidal attempt

Cancer (active diagnosis, active treatment, or in remission or cancer-free for less than 5 continuous years)

History of organ transplant on anti-rejection medication

Severe gastrointestinal condition (gastroparesis, blockage, inflammatory bowel disease)

MI (myocardial infarction) / CVA (cerebrovascular accident) in the past 12 months

Personal or family history of thyroid cyst/nodule, thyroid cancer,medullary thyroid carcinoma, or multiple endocrine neoplasia syndrome type 2

History of or current pancreatitis

Diabetic retinopathy (diabetic eye disease)

None of the above

NOTE TO FEMALE PATIENTS OF REPRODUCTIVE POTENTIAL IF ‘NONE OF THE ABOVE’ IS SELECTED: Please note that we strongly recommend that you use an effective method of contraception during treatment with a GLP-1 medication and for at least 2 months thereafter. For those taking Zepbound or Mounjaro (tirzepatide), we recommend switching to a non-oral contraceptive method or adding a barrier method of contraception for four weeks after initiation and for four weeks after each dose escalation. For any questions or concerns regarding your specific situation, please speak to your medical provider.

Based on the age, BMI, or potentially the medical conditions you’ve provided us, it appears you don't meet the eligibility criteria for our program. If you think this might be a mistake, please review your submission to ensure all information is correct.

Congratulations ,
you are qualified.

Please Select Your Weight Loss Treatment Below:

Compounded Semaglutide

average 16% body weight loss

Semaglutide is a weekly GLP-1 injection that curbs appetite, hunger, and cravings by mimicking your body’s natural processes.

Same active ingredient as Ozempic® & Wegovy®

START FOR ONLY $399/month

Compound Tirzepatide

average 22% body weight loss

Tirzepatide is the most effective GLP-1 medication for weight loss as it also works on GIP receptors, achieving weight loss even more efficiently.

Same active ingredient as Mounjaro® & Zepbound®

START FOR ONLY $499/MO

Now Please Select Your Current Treatment Dose

Company

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