Weight Loss Inquiry

Welcome! Let's get started with some health questions.

We appreciate your interest in our weight loss program. Before proceeding, we kindly ask you to confirm that you DO NOT have any of the following conditions, as they will affect your eligibility for this service:

Personal History of Pancreatitis: Our treatments may not be suitable for individuals who have previously suffered from pancreatitis.

Personal or Family History of Medullary Thyroid Cancer: If you or a close family member have been diagnosed with medullary thyroid cancer, our weight loss medications may not be appropriate for you.

Pregnancy or Breastfeeding: Our weight loss injections are not recommended for individuals who are pregnant or breastfeeding.

Type 1 Diabetes: Individuals with Type 1 Diabetes should not use our weight loss medications, as they may interfere with insulin regulation and other essential treatments.

Under the age of 18 | 75 yrs. or older: We want to ensure that our weight loss program is safe and effective for individuals of all ages, so we do take your age into consideration when determining your eligibility for our program. Those under the age of 18 and 75 years or older do not qualify.
I DO NOT have any of the disqualifiers listed above*

(Select)

Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com

To help us create your customized dosing program, our on-site medical professionals need to gather the following information. To learn more, please click on the dropdown at the bottom of the page.
Height (ft)*
Height (in)*
TOTAL Height (in)
Weight (lb)*
BMI
Date of Birth MM/DD/YYYY*

MonthDayYear
Age
Inquiry Source
Gender*
Are you currently prescribed/taking medications for any thyroid related conditions? (For example, Levothyroxine, Synthroid, Cytomel, etc.)*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Today's Date

MonthDayYear
Date

Learn more about how we use this information to customize your program.
At FIKA INFUSION + WELLNESS, your health and well-being are our top priorities. In order to provide you with the most personalized and effective weight loss solutions, we require some essential information about you. Here's why:

Height & Weight: Understanding your current physical measurements helps us tailor our weight loss injections to your unique body composition. This ensures that our treatments are not only effective but also safe for you.
Date of Birth: Your age plays a vital role in determining the most suitable weight loss approach. By knowing your date of birth, we can align our treatments with your metabolic rate, lifestyle, and other age-related factors.
Gender: Your gender helps us further personalize your treatment plan. Different genders may have varying metabolic rates, hormonal balances, and nutritional needs. By selecting the option that best represents you, we can create a weight loss program that aligns with your individual characteristics.
Address: We ask for your address to facilitate the ordering of necessary lab work. This information enables us to coordinate with local laboratories and healthcare providers to ensure a seamless and convenient experience for you.

Your Privacy Matters to Us: We want you to feel confident and secure in providing this information. All personal details are handled with the utmost care and confidentiality, in compliance with all applicable privacy laws and regulations. Your information will only be used for the purposes outlined above and will never be shared with unauthorized third parties.

If you have any concerns or questions about this process, please don't hesitate to reach out to our guest experience specialist at 801.866.2201

We're here to assist you every step of the way.

Everything's Looking Good So Far!

At FIKA INFUSION + WELLNESS, we prioritize your unique wellness journey. Our personalized approach includes medications that not only enhance your chances of successfully losing weight but also take significant steps to improve your A1C and Lipid levels. Additionally, our medical team offers the option to include extra labs, ensuring we track progress, tailor your program, and measure your overall wellness.

Recommended OPTIONAL Tests Include:

• Hemoglobin A1c Test: This test is $27 and provides insight into your blood sugar levels over the past three months. Monitoring your A1C levels can help us tailor your treatment to your specific needs and reduce the risk of type 2 diabetes.

• Lipid Panel Test: This test is $41 and provides a detailed report of your blood fats. Managing your lipid levels not only enhances the effectiveness of our medications but also reduces the risk of heart disease.
We respect your individuality and want to build a program that is right for you. Check any boxes below to notify our medical team that you're interested in having either/both or neither of these tests incorporated if you're accepted into the program.*

Hemoglobin A1c TestLipid Panel TestNo, but thank you for asking😊
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Welcome! Let's get started with some health questions.

At FIKA INFUSION + WELLNESS, your health and well-being are our top priorities. In order to provide you with the most personalized and effective weight loss solutions, we require some essential information about you. Here's why: