Weight Loss - V LINE AESTHETICS

What is your weight loss goal?

What is your current height & weight?

YOUR BMI:

0.00

FEET *

INCHES *

WEIGHT (IN LBS) *

Thank you for your interest in our weight loss program. Based on your BMI, you do not meet the eligibility criteria at this time. We encourage you to explore other resources or consult a healthcare professional for guidance.

What is your gender?

MALE
FEMALE

What is your date of birth?

Are you currently taking or have recently (within the last 12 months) taken medication(s) for weight loss?

Yes, I currently take or have recently (within the last 12 months) taken a GLP-1 medication for weight loss

Yes, I currently take or have recently (within the last 12 months) taken another medication for weight loss

Have you taken any prescription medications to lose weight before?

Yes

Are you currently taking, plan to take, or have recently (within the last 3 months) taken opiate pain medications and/or opiate-based street drugs?

Yes

IF YES, PLEASE PROVIDE:

Have you had prior bariatric (weight loss) surgery or any abdominal/pelvic surgeries?

Yes

IF YES, PLEASE PROVIDE:

Are you willing to

Neither of these

Reduce your caloric intake alongside medication, if clinically appropriate

Increase your physical activity alongside medication, if clinically appropriate

Fasting glucose value

What was your most recent fasting glucose value?

I'm not sure

What was your most recent hemoglobin A1c (HbA1c) value?

I'm not sure

What is your current or average blood pressure range?

What is your current or average resting heart rate range?

Do you have any medication allergies?

Yes

IF YES, PLEASE PROVIDE:

Are you concerned about any of the following to the level of impacting your ability to take medication regularly?

None of the below

Injecting yourself under the skin with a needle

Nausea or vomiting as a side effect

Loss of muscle mass as a side effect

Do you have any further information which you would like the doctor to know?

Yes

IF YES, PLEASE PROVIDE:

What is your first and last name?

FIRST NAME *

Last name *

What is your email?

What is your phone number?

Business Hours:

Contact

care@SkinPerfectMedSpa.com

1569 S. Fairway Drive Suite 226
Walnut, CA USA 91789

909.839.0714

Business Hours:

Sunday – Closed

Monday -Closed

Tuesday – 9:30AM-5:30PM

Wednesday – 9:30AM-5:30PM

Thursday – 9:30AM-5:30PM

Friday – 9:30AM-5:30PM

Saturday – 9:30AM-5:30PM

YOUR BMI:

Business Hours:

Contact

Business Hours:

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