FMC Weight Loss Intake Form
FMC Weight Loss Intake Form
1
2
3
4
5
You’re taking the first step toward a healthier, more confident you. This form helps us understand your story so we can create a plan tailored just for you. Your answers are private, your journey is personal, and we’ll be here to support you every step of the way.
Please enter your first and last name
What is your address?
Start typing your street address and choose the correct suggestion.
What is your date of birth?
Based on your date of birth our doctors can prescribe the proper weight loss prescription.
What was your gender at birth?
What is your height and weight?
This information will be used to calculate your Body Mass Index (BMI) for diagnostic purposes. Please note that BMI is a measure of body size and is not, by itself, a comprehensive assessment of overall health.
ft.
in.
lbs.
lbs.
Every journey begins with one step—this is yours. We’ll walk it with you.
Please enter your email address
Please enter your phone number
-
Can we send you text messages about your prescription?
(including tracking information and refill information)
Help us understand your medical picture.
What medications are you currently taking?
Please list all prior surgeries
Please list any diagnoses, ongoing conditions, and relevant medical history
Do any of the following apply to you?
Select all that apply.
Have you ever been diagnosed with, or treated for, any of the following medical conditions?
Select all that apply.
Do you have any allergies? *
Strong choices. Real change. Lasting results.
Do you currently take weight loss medication?
Almost Done.
Please provide a valid form of Identification. *
Terms & Policies *
Cancellation / No-Show Policy *

About Us

 

Welcome to FMC;
Your virtual weight loss companion


Founded on the principles of promoting a balanced lifestyle and sustainable weight management, FMC has garnered a loyal following of individuals seeking effective solutions for their weight loss journey. With a strong emphasis on science-based approaches, FMC offers personalized weight loss programs tailored to each individual's unique needs and goals.

The core of FMC success lies in its team of experienced medical professionals who work collaboratively to design comprehensive and evidence-based weight loss plans.

Through its unwavering commitment to empowering individuals to achieve sustainable weight loss, FMC has transformed countless lives, fostering a community of success stories and positive transformations.

As the company continues to innovate and evolve, it remains a beacon of hope for those seeking a healthier and happier life, using our unique three-step weight loss and management process.

Our Unique Three-Step Process:

We understand that time is of the essence, especially when it comes to your health. Our seamless three-step process utilizes cutting-edge technology and the expertise of our highly-qualified doctors to dramatically shorten the time it takes to get you started on your weight loss journey.

1. Virtual Consultation: Connect with a licensed medical professional through our secure telehealth platform (audio-visual) and discuss your weight loss concerns and goals from the comfort and safety of your home.

2. Personalized Prescription: Our doctors will evaluate your medical intake form and prescribe the most suitable GLP-1 weight loss medication for you.

3. Direct Medication Delivery: Shipment of your GLP-1 medication is included in your subscription plan, and is shipped directly to your doorstep.

Our Promise:

At FMC, we stand by the quality of our service and are dedicated to providing an exceptional healthcare experience. Your well-being is our top priority, and as you embark on your weight loss journey, we are here to support you every step of the way.

Join Us on Our Mission:

We invite you to be part of the FMC weight loss community and help us create a brighter, healthier future for all.