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Intake Form

Contact Information

This form takes approximately 2–3 minutes to complete.

What are your weight loss goals?

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

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.

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 *

Please enter a number greater than or equal to 1
Please enter a number from 0 to 11

Are you currently taking any GLP-1 medications? *

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 *

Please upload a government-issued photo ID *

You may upload any government-issued photo ID, including a driver's license, passport, state ID, or foreign government-issued ID, such as a Mexican ID.

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

Consent & Attestation

Please review and attest to the following before continuing.
Consent: I confirm that I am the patient completing this intake form and have reviewed all questions carefully. I attest that my answers are true, accurate, and complete to the best of my knowledge. I understand the importance of providing my doctor with complete and accurate health information for my care. *

Final Step! – Please confirm that all the information you've provided is true and complete.Consent: I confirm that I am the patient completing this intake form and have reviewed all questions carefully. I attest that my answers are true, accurate, and complete to the best of my knowledge. I understand the importance of providing my doctor with complete and accurate health information for my care. *

Billing Information

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Questions Call: 877- 5-VIDAMED (877-584-3263)

EMAIL: HELP@ MYVIDAMED.COM
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© 2026 Vidamed LLC | All Rights Reserved
Vidamed provides access to licensed US healthcare providers. Eligibility varies by state, and prescriptions are provided only if clinically approved. The information on this website is for educational purposes only and is not intended as medical advice, diagnosis, or treatment. Always consult with a qualified healthcare provider before starting any new treatment. Individual results may vary. Vidamed does not guarantee specific outcomes. By using Vidamed services, you agree to our Terms of Service and Privacy Policy.
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