Submit Your CV Intake Form | Vida Medical Services

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First Name(Requerido)

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Last Name(Requerido)

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Email(Requerido)

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Phone(Requerido)

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¿Cuáles son tus objetivos de pérdida de peso?(Requerido)

Bajar entre 1 y 20 lbs de manera definitiva

Bajar entre 21 y 50 lbs de manera definitiva

Bajar más de 50 lbs de manera definitiva

Mantener mi peso saludable

Ninguna de las anteriores

Otro

Other(Requerido)

¿Qué métodos para bajar de peso has intentado anteriormente? Selecciona todos los que apliquen(Requerido)

Ejercicio, Dietas

Suplementos para perder peso

Ayuno intermitente

Ninguna de las anteriores

¿Qué opción de tratamiento te interesa más?(Requerido)

Nota: Todas las opciones incluyen medicamento GLP-1 personalizado según tu proveedor, los insumos necesarios, acompañamiento médico continuo y envío gratuito a nivel nacional. Los planes de 3 meses se cobran en un solo pago inicial.

Importante: Solo se realizará el cobro si el médico aprueba el tratamiento. Si no calificas, no se hará ningún cargo. VidaMed no realiza cargos automáticos. Tu tarjeta se guarda de forma segura en el portal para evitar volver a ingresarla. Si el médico aprueba tu plan, se realizará el cobro correspondiente. Para quienes eligen el plan de 3 meses, se hace un solo pago de $597. Siempre recibirás recordatorios por texto/correo para aprobar futuros resurtidos.

Estatura (ft)(Requerido)

Please enter a number greater than or equal to 1.

Ingresa un número mayor o igual a 1

Estatura (in)(Requerido)

Please enter a number from 0 to 11.

Ingresa un número entre 0 y 11

Peso (lbs)(Requerido)

IMC

Género(Requerido)

Masculino

Femenino

Fecha de nacimiento(Requerido)

¿Estás tomando actualmente algún medicamento GLP-1?(Requerido)

Sí

Which GLP-1 medication are you currently taking?(Requerido)

Compounded Semaglutide Injections

Compounded Tirzepatide Injections

Branded Semaglutide (Wegovy or Ozempic)

Branded Tirzepatide (Zepbound or Mounjaro)

Oral Semaglutide

Oral Tirzepatide

What was the approximate date of your last dose?(Requerido)

What was the strength of your last dose?(Requerido)

Please provide strength of last dose in milligrams (mg) if known

¿Estás embarazada, en período de lactancia o planeas quedar embarazada en los próximos 2 meses?(Requerido)

¿Estás tomando actualmente algún medicamento? Incluye recetas, medicamentos de venta libre y suplementos(Requerido)

Enumere todos los medicamentos que está tomando actualmente:(Requerido)

Indica cualquier cirugía que hayas tenido en el pasado: Si no has tenido ninguna, escribe N/A(Requerido)

Lista todas tus alergias conocidas: Si no tienes, escribe N/A(Requerido)

Sube una identificación oficial (licencia de conducir, pasaporte, etc.)(Requerido)

Accepted file types: jpg, gif, png, pdf, Max. file size: 512 MB.

Asegúrese de que su nombre completo y foto sean fácilmente visibles.

¿De qué manera prefieres la consulta?(Requerido)

Correo electrónico y mensaje de texto (la opción más rápida)

Videollamada

Llamada telefónica

What is your preferred language for communication with our medical team? (¿Cuál es su idioma preferido para comunicarse con nuestro equipo médico?)(Requerido)

English / Inglés

Spanish / Español

Dirección(Requerido)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Stripe Setup ID(Requerido)

Important: The patient will only be charged if the physician approves the medication. If they do not qualify, no charge will be made. VidaMed does not auto-charge. Your card is securely stored in the portal so you don’t have to re-enter it. You will only be charged once the physician approves your treatment plan. If you do not qualify, no charge will be made. For patients choosing the 3-month supply, it is a one-time charge of $597. You will always receive text/email reminders to approve future refills.

Promo Code

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Product ID

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Product Name

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Product Bundle ID

hCaptcha

What is your age?(Required)

What anti-aging goals do you have for your skin? Please select all that apply.(Required)

Reducing fine lines and wrinkles

Improving skin texture (finer, smoother skin)

Improving plumpness/firmness

Reducing dark spots and uneven skin tone

Reducing facial hair/hursutism

Other

Other(Required)

What other goals do you have for your skin? Select all that apply.(Required)

Treating/reducing acne breakouts

Treating rosacea

Treating eczema

Other

Other(Required)

Please select how dry/oily your skin is.(Required)

Very dry

Somewhat dry

Combination skin type

Somewhat oily

Oily

How sensitive is your skin?(Required)

My skin is easily irritated

My skin can get irritated at times

My skin is rarely irritated

I'm not sure

Are you currently using tretinoin, retin-A, or other retinol product?(Required)

Yes

What strength tretinoin or retin-A are you using?(Required)

~0.025%

~0.05%

~0.08%

~0.1%

I'm using a different retinol product, I'm not sure

Do you have any of the following skin conditions? Please select all that apply.(Required)

Acne

Rosacea

Eczema or atopic dermatitis

Skin cancer

Other

None of these

Please list all current medical conditions. Please type N/A if none.(Required)

Please list allergies to prescription or over-the-counter medicines, herbs, vitamins, supplements, food, dyes, or anything else. Please type N/A if none.(Required)

Please list any prescription or over the counter medications or supplements you are taking. Please type N/A if none.(Required)

Which of the following do you use. Please select all that apply.(Required)

Sunscreen

Moisturizer

Cleanser

Makeup

Other

None of these

Is there anything else you want to tell your doctor?(Required)

Yes

Please leave your message to your doctor here.(Required)

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Weight

Please upload a government issued form of ID (Driver's License, Passport, etc). Please be sure that your full name and photo are easily visible.(Required)

Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB.

What is your preferred language for communication with our medical team? (¿Cuál es su idioma preferido para comunicarse con nuestro equipo médico?)(Required)

English / Inglés

Spanish / Español

First Name(Required)

Last Name(Required)

Email(Required)

Phone(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Stripe Setup ID(Required)

Promo Code

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Product ID

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Product Name

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Product Bundle ID

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How do you rate your confidence that you could get and keep an erection?(Required)

When you have erections with sexual stimulation, how often are your erections hard enough for penetration?(Required)

Almost never or never

A few times (less than half the time)

Sometimes (about half the time)

Most times (more than half the time)

Almost always or always

How often were you able to maintain your erection for a long enough period to satisfy yourself and your partner?(Required)

Almost never or never

A few times (less than half the time)

Sometimes (about half the time)

Most times (more than half the time)

Almost always or always

During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?(Required)

Extremely difficult

Very difficult

Difficult

Slightly difficult

Not difficult

When you attempted sexual intercourse, how often was it satisfactory to you?(Required)

Almost never or never

A few times (less than half the time)

Sometimes (about half the time)

Most times (more than half the time)

Almost always or always

How did your ED begin?(Required)

Gradually, but has worsened over time

Suddenly, but not with a new partner

Suddenly, with a new partner

I don't know how it began

How satisfied have you been with your overall sex life?(Required)

Have you tried ED medication before?(Required)

Yes

If yes, please list medication(s) previously tried:(Required)

Have you ever been diagnosed with or treated for high or low blood pressure?(Required)

Yes, for high blood pressure

Yes, for low blood pressure

I'm not sure

Have you ever been diagnosed with any of these heart conditions?(Required)

Arrhythmia

Coronary artery disease (narrowing of the heart vessels)

Coronary bypass surgery, Heart attack

Idiopathic Hypertrophic Subaortic Stenosis (aka hypertrophic obstructive cardiomyopathy)

Long QT Syndrome

Any congenital or developmental heart problems

Pulmonary HTN (a rare condition that refers to the blood vessels to the lungs and isn't the same as high blood pressure)

Heart failure

None of these

Do you experience any of these symptoms? (Please check off all that apply)(Required)

Chest pain when climbing stairs or walking

Chest pain during sexual activity

Sudden loss of vision due to loss of blood flow to your eye (aka anterior ischemic optic neuropathy)

Unexplained fainting or dizziness

Cramping or pain in the calves or legs with exercise (aka claudication)

None of these

Have you used any of these recreational drugs in the last 6 months?(Required)

Crystal meth (methamphetamines or amphetamines)

Poppers or Rush

Amyl Nitrate or Butyl Nitrate

Cocaine

Molly (MDMA, ecstasy)

No, I haven't used these recreational drugs in the last 6 months

Please list all current medical conditions. Please type N/A if none.(Required)

Do you currently use or have prescriptions for any of these medications?(Required)

Any medication containing nitrates

Any ALPHA blocker, NOT beta blocker (like Flomax, Cardura, and Minipress)

Nitroglycerin in any form (spray, tablet, patch, or ointment)

Supplements that boost nitric oxide (like L-arginine, L-citrulline, beet root powder/extract/juice concentrate)

Monoket (isosorbide mononitrate), Bidil, or Isordil (isorbide dinitrate), which are commonly prescribed to prevent chest pain caused by heart disease)

Antiretrovirals or any treatment for HIV

Adempas (riociguat)

None of the above

Please list all prescription or over-the-counter medications and supplements you are currently taking. Please type N/A if none(Required)

Please list allergies to prescription or over-the-counter medicines, herbs, vitamins, supplements, food, dyes, or anything else. Please type N/A if none(Required)

Is there anything else you'd like your provider to know?(Required)

Yes

Please leave your message to your doctor here.(Required)

ED can be a sign of other undiagnosed medical issues, like heart problems. Smoking, marijuana use, obesity, depression, and low testosterone can all play a role in erectile function (and dysfunction). In addition to seeking ED treatment, we recommend you speak with your primary care provider to rule out other underlying conditions.

Let's talk about treatment preferences. If you have any preferences, we want to take those into account. Your provider will still review everything and make sure you're getting the best treatment for you.

Which treatment option best fits your needs?

Sildenafil

Tadalafil

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Weight

What is your preferred language for communication with our medical team? (¿Cuál es su idioma preferido para comunicarse con nuestro equipo médico?)(Required)

English / Inglés

Spanish / Español

First Name(Required)

Last Name(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Stripe Setup ID(Required)

Promo Code

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Product ID

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Product Name

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Product Bundle ID

Turnstile

How satisfied are you with your hair overall?(Required)

What are your top-priority goals for hair loss treatment?(Required)

I want to prevent further hair loss

I want to regrow hair

I want fuller, thicker-looking hair

I have a full head of hair I'd like to maintain

Where are you noticing hair loss or thinning?(Required)

Both hairline and crown

Receding hairline (along my forehead or temples)

Thinning crown (top of my head)

Overall thinning

Random golf-ball size bald patches scattered all over scalp

Nowhere yet, but I'd like to prevent future hair loss

Have you ever treated your hair loss with medication?(Required)

Yes

Have you ever been diagnosed with or treated for high or low blood pressure?(Required)

Yes, I have been diagnosed or treated for high blood pressure

Yes, I have been diagnosed or treated for low blood pressure

I'm not sure

Please list any prescription medications, over-the-counter medications, vitamins, dietary supplements, and topical creams you are currently taking or using, including dosages. Please type N/A if none.(Required)

Are you allergic to any of the following? Please select all that apply.(Required)

Finasteride (oral or topical)

Minoxidil (oral or topical)

Ketoconazole (oral or topical)

Latanoprost

None of the above

Please list all of your known allergies. Please type N/A if none.(Required)

Is there anything else you want your doctor to know about your condition or health?(Required)

Yes

Please leave your message to your doctor here.(Required)

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Weight

What is your preferred language for communication with our medical team? (¿Cuál es su idioma preferido para comunicarse con nuestro equipo médico?)(Required)

English / Inglés

Spanish / Español

First Name(Required)

Last Name(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

This field is hidden when viewing the form

Stripe Setup ID(Required)

Promo Code

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Product ID

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Product Name

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Product Bundle ID

Turnstile

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