Medical Questionnaire, New Hope Weight Loss

Step 1: Contra-Indicated Conditions

Please check all that apply. These conditions prevent treatment with GLP-1 medications.

End-stage kidney disease (on or about to be on dialysis) End-stage liver disease (cirrhosis) Current suicidal thoughts and/or prior suicidal attempt Cancer, active diagnosis, active treatment, or in remission/cancer-free less than 5 years (excludes non-melanoma skin cancer cured via simple excision) History of organ transplant on anti-rejection medication Severe gastrointestinal condition (e.g., gastroparesis, inflammatory bowel disease) Current diagnosis of or treatment for an eating disorder (anorexia nervosa or bulimia nervosa) Personal or family history of Medullary Thyroid Carcinoma (MTC) or Multiple Endocrine Neoplasia Syndrome Type 2 (MEN-2) Currently pregnant, breastfeeding, or planning to become pregnant within 2 months

None of these conditions apply to me

We're Unable to Proceed

Thank you for walking through our Medical History/Medical Intake questionnaire. Please seek the advice and counsel of your Primary Care Physician (PCP) as we will be unable to progress further. Any monies paid will be fully refunded.

Checked a box by mistake? Simply uncheck it to continue. Not sure whether a condition applies to you? Call us at (657) 837-3342 and we will tell you honestly whether this program is a fit.

Step 2: Additional Health History

Check all that apply. This information will be reviewed by our physician to ensure safe, personalized treatment.

None of these conditions apply to me

Step 3: Your Contact Information

Almost done. Confirm your contact details and add your shipping address. For your privacy, the quiz and this medical form are stored separately, so we ask again here.

First Name *

Last Name *

Date of Birth *

Email *

Phone *

Shipping / Mailing Address

Street Address *

City *

State *

Telehealth service is available for eligible California patients. For other locations, availability depends on licensure and separate dispensing-pharmacy confirmation.

ZIP Code *

Next step after you submit: secure checkout for your one-time $119 physician review. Medication is separate (compounded semaglutide from $166/mo, tirzepatide from $233/mo) and is only charged if the physician prescribes it for you. Compounded medications are not FDA-approved and not brand-identical; results vary. HSA/FSA accepted; Cherry, Klarna, and Affirm financing available. See payment options.

By submitting, you agree to our Privacy Policy and HIPAA Notice, and consent to be contacted by our medical team.

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Questionnaire Submitted!

Your medical questionnaire has been submitted for physician review. Continue to secure checkout to complete your one-time $119 physician review. Medication is separate and is only charged if prescribed.

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Questions? Call (657) 837-3342