Empathetix Wellness is happy to now offer
Semaglutide Weight Loss Injections
Basic Patient Information
To schedule your free, no-commitment phone consultation with our doctor.
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Street Address Line 2
State / Province
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How would you best describe your gender?
Male (including transgender men)
Female (including transgender women)
Prefer Not to Say
Current Weight (In Pounds)
Goal Weight (In Pounds)
Please answer these questions truthfully and to the best of your knowledge. This will allow us to design a treatment plan specifically designed for you. Your honest answers are greatly appreciated.
Do you take any medications or supplements?
Please list all medications or supplements you are taking:
Do you have allergies to any medications?
Please list all medication allergies you have:
Check if you have had any of the following now or in the past:
Type 1 Diabetes
ESRD on Dialysis
Medullary Thyroid Carcinoma (MTC)
Multiple Endocrine Neoplasia Syndrome Type 2 (MEN 2)
Other medical conditions (please list):
Previous Weight Loss History
Please check all previous weight loss methods you have tried:
Atkins or Low Carb Diets
Weight Loss Programs
Other methods (please list):
What are your goals for treatment? Do you have any specific concerns you would like addressed?
I acknowledge that all the information is true and accurate to the best of my knowledge.
How did you hear about Empathetix?
Mobile Med Clinic
Helper Saturday Vibes
Sign Around Town
Word of Mouth
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