Vidamed Call Center Intake Form

First Name*

Last Name*

Phone*

Email*

Do you know your BMI (Body Mass Index)? *

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

How old are you? (Just a number, but it helps us tailor our recommendations!) *

Are you currently taking any GLP-1 medications? (Medications like Ozempic, Wegovy, etc.) *

Yes No

If yes, which one are you taking? (Please select the name!) *

Compounded Semaglutide Injections Compounded Tirzepatide Injections Branded Semaglutide (Wegovy or Ozempic) Branded Tirzepatide (Zepbound or Mounjaro) Oral Semaglutide Oral Tirzepatide

When was your last dose? (An estimate is fine!) *

What was the strength of your last dose? (In milligrams (mg) if you know it!) *

How are you doing with your medication? (Are you noticing any side effects? Is it working well for you? We'd love to hear your thoughts!) *

I’m NOT losing weight (1-2 pounds/week) and I’m NOT having side effects. I’m NOT losing weight (1-2 pounds/week) and I AM having side effects. I’m losing weight (1-2 pounds/week) but I AM having side effects. I’m losing weight (1-2 pounds/week) and I’m NOT having side effects.

Is there a particular medication you are interested in discussing with your provider? (Please list below)

Compounded Semaglutide Injections Oral Semaglutide Tablets No preference, go with doctor recommendation

Are you pregnant, breastfeeding, or planning to be in the next 2 months? (This helps us provide the safest recommendations!) *

Yes No

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

Have you ever had surgery? (If so, please list them or type “N/A” if none.) *

Do you have any allergies? (If none, just 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

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. *

I agree and consent

Not sure which medication to choose?

Answer these questions to find the right one for you.

Ready to Transform?

Let's start with your name and email to personalize your care and save your progress.

Email*

First name*

Last Name*

Reach your ideal weight without impossible diets.

What is your height and weight?

Height

Weight in lbs

Perfect! With a BMI of [X], we can continue.

We're in this together. Your goal is our goal.

What is your ideal weight?

Are you male or female? Male Female

Safety, first.

Do any of these apply to you?

Currently or possibly pregnant, or actively trying to become pregnant Breastfeeding or bottle-feeding with breastmilk Have given birth to a child within the last 6 months None of the above

Improving your life requires motivation.

What is your primary reason for looking into GLP-1 medication?

I want to live longer I want to feel and look better I want to reduce current health issues All of these

GLP-1s help you lose weight at a pace that works for you

How quickly are you hoping to reach your goal?

I'm fine taking it slow I'd like to see faster results I'm in no rush — steady is best

GLP-1 is safe, but these health conditions might prevent you from being prescribed.

Your answers are completely confidential and protected by HIPAA.

Do you have any of the following conditions? (select all that apply) High blood pressure High cholesterol Diabetes Heart disease Thyroid issues None of the above I'm not sure

A few more health questions

Do you have any of the following conditions? (select all that apply)

Kidney disease Liver disease Cancer Autoimmune disorder None of the above I'm not sure

Have you taken medication for weight loss within the past 4 weeks?* Yes, I've taken GLP-1 medication Yes, I've taken a different medication for weight loss No

Have you had prior weight loss surgeries? Yes No

If clinically appropriate, are you willing to: Reduce your caloric intake alongside medication Increase your physical activity alongside medication None of the above

Has your weight changed in the last year? Lost a significant amount Lost a little About the same Gained a little Gained a significant amount

If you have any known allergies, please list them here.

Which of these is most important to you? Lowest price Faster results Balanced option

Format preference I prefer to inject I prefer a tablet

Do you currently take any medications? Yes No

How motivated are you to reach [ideal weight]? I'm Ready! I'm feeling hopeful I'm cautious

Your responses will be reviewed by a doctor within two business days.

Do you have any further information which you would like our medical team to know? Yes No

Your consultation will be by text or email for convenience and speed.

If you have special circumstances, you can request a phone or video call with your doctor after completing this form.

In most cases, the info you've provided on this form will be enough for a doctor to make a decision.

What is your preferred language for communicating with our support team and medical doctors? English Spanish No preference

What is your date of birth?

Date of birth

Your Medical Review

BMI: [X] Current: [X] lbs Goal Weight: [X] lbs

Your transformation is closer than you think!

Let's proceed to check your eligibility.

What state will your medication be shipped to?

[NAME] how can you be reached if necessary?

Our medical team uses email and text for patient communication, as well as updates about programs and services.

Phone number

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.

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? *

Yes No

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.

Drag & drop your file here or click to upload

Accepted: JPG, PNG, PDF (Max 5MB)

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 *