Your Journey. Your Wellness. Our Expert Care.

Your transformation begins here. Fill out the form below to connect with Virtual NP Medicine, and take the first step toward sustainable, medically guided weight loss.

Consultation Form

First name

Last name

Phone

Residing State

Gender

Height

Date of Birth

Weight

Treatments of Interest

Do you have any personal or family history of medullary thyroid carcinoma (MTC) or multiple endocrine neoplasia type 2 (MEN 2)?

Do you have a history of an eating disorder? If so, please explain.

Do you have a history of pancreatitis?

Have you experienced severe gastrointestinal symptoms (e.g., severe nausea, vomiting) with past medications?

Do you have any concerns about taking weight loss medication?

Have you previously used GLP-1 medications (e.g., semaglutide, tirzepatide, liraglutide)?

Is there anything else you would like your provider to know about your health or goals?

General Concerns

Weight Loss

Do you experience any weight-related complications?

What is your target weight or weight loss goal?

How long have you been experiencing weight-related health challenges?

Have you tried other weight loss methods (e.g., diet, exercise, medications) in the past?

What is your primary goal(s) for seeking weight loss treatment?

Medical History

Do you have any known allergies to medications or injections?

Do you have any diagnosed medical conditions or medical problems?

Do you have a personal or family history of the following conditions? (Thyroid cancer, Diabetes type 1, Kidney disease).

Are you currently pregnant, breastfeeding, or planning to become pregnant?

Are you currently taking any medications or supplements?

Lifestyle & Activity

Do you currently monitor any health markers (e.g., glucose levels, bone density, cholesterol, blood pressure)?

Do you have any dietary restrictions, allergies, or follow any specific dietary patterns (e.g., vegetarian, keto, intermittent fasting)?

Do you engage in regular physical activity?

Have you noticed significant weight changes recently (gain or loss)?

Do you have any dietary restrictions or food allergies?

Disclaimer & Consent

I confirm that all my answers are accurate and complete.

Yes

Do you consent to this information being reviewed by a licensed medical professional to determine your eligibility for care?

Yes

Addition Notes