Name: Skinly Aesthetics
Price range: $

Name(Required)

First Last

Date ff Birth(Required)

Sex(Required)

Male

Female

Phone Number(Required)

Email Address(Required)

Are you here to be evaluated for weight loss?(Required)

Yes

No

Do you have any of the following medical problems?(Required)

Cirrhosis/liver disease

End stage renal failure

None of the above

Do you have any of the following medical problems?(Required)

Have you ever attempted to lose weight through a weight management program longer than 6 months?(Required)

Yes

No

Are you willing to reduce your caloric intake alongside medication?(Required)

Yes

No

Are you willing to increase your physical activity alongside medication?(Required)

Yes

No

Have you ever dealt with following:(Required)

Anorexia nervosa

Bulimia nervosa

None of the above

Are you taking any medications?(Required)

Yes

No

Current Medications:(Required)

Please list the generic name of your medication, the dose, how many times per day, how long you have been on this medication.

Did you ever have any type of thyroid cancer?(Required)

Yes

No

Please type the thyroid cancer type/s you have or had?(Required)

Do you have any allergies to medications?(Required)

Yes

No

List your medication allergies(Required)

What is your goal weight?(Required)

Current Weight (lb)(Required)

Height: 5 ft 08 inch(Required)

Please provide a recent blood pressure measurement within the last 6 months, which should be listed as follows: Systolic (top number)/Diastolic (bottom number)(Required)

If you are not sure, please go have your blood pressure obtained (typically free at your local pharmacy).

Are you pregnant or expecting to be?(Required)

Pregnant

Breastfeeding or lactating

Expecting to be pregnant

No or Doesn’t apply

Where do you live?

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Photo of Your Drivers License(Required)

Accepted file types: jpg, jpeg, png, pdf, heic, raw, Max. file size: 50 MB.

Your photo in active wear or swimsuit(Required)

Accepted file types: jpg, jpeg, png, pdf, heic, raw, Max. file size: 50 MB.

Untitled(Required)

By checking the box below I understand that I will be charged a monthly enrollment fee as part of my contract that will be provided to me in a separate document.

Semaglutide assessment form

Where do you live?