Vidamed Call Center Intake Form

Contact Information

This form takes approximately 2–3 minutes to complete.

First Name*

Last Name*

Phone*

Email*

Zip Code*

What are your weight loss goals?

Lose 1-20lbs for good Lose 21-50lbs for good Lose over 50lbs for good Maintain my healthy weight None of the above Other

What weight loss initiatives have you tried in the past? Select all that apply *

Exercise, Dieting Weight-loss Supplements Intermittent Fasting None of the Above Other

Treatment Options

Which treatment option are you most interested in? Note: All options include personalized compounded medication as prescribed by your doctor, all necessary supplies, ongoing medical support, and free nationwide shipping. *

Note: All options include personalized compounded medication as prescribed by your doctor, all necessary supplies, ongoing medical support, and free nationwide shipping.

Important:

You will only be charged if the doctor approves the medication. If you 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
For Monthly plans: you're charged the first month price. Subsequent months are charged at regular price only after your approval.
For 3-month plans: it's a single upfront payment of the total amount.
You will always receive text/email reminders to approve future refills.

Physical Measurements

Please provide your physical measurements and demographic information *

Height (ft) Please enter a number greater than or equal to 1

Height (in) Please enter a number from 0 to 11

Weight (lbs)

BMI

Gender

Male Female

Date of Birth

Are you currently taking any GLP-1 medications? *

Yes No

Are you currently pregnant, breastfeeding, or planning to become pregnant within the next 2 months? *

Do you have any of the following conditions? Did you have any in the past? (Select any that apply.) *

Please check all current or past medical conditions. Select all that apply *

Are you currently taking any medications, including prescriptions, over-the-counter meds, or supplements? If yes, please list them here! (The more details, the better!) *

Do you have any allergies? (If none, just type “N/A.”) *

List any surgeries you have had in the past: If you haven't had any surgeries, type N/A *

Which type of consultation do you prefer? (Let us know what works best for you!) *

Email and Text Message (Fastest Option) Video Phone Call

Consent & Attestation

Billing Information

Address *

Street Address

City *

State / Province *

ZIP / Postal Code *

Country

Promo Code

Payment *