Weight Loss Intake Form - Wally Moon Telehealth

Congrats on taking the first step to weight loss with Wally Moon!
This questionnaire will provide our Doctors important information so they can assess your condition and prescribe medication if appropriate.
By clicking "START" below you consent Telehealth , Privacy Policy and Terms.

Please select your State: (We need to confirm that we are licensed in your state)(Required)

Unfortunately, we cannot service this condition in your state. Please contact your local physician for assistance.

Your state may require a phone or video consultation to complete your treatment. Don't worry!
Your doctor will reach out to you if this is the case.

What is your full name?(Required)

First Name Last Name

Please provide your email address:(Required)

Consent(Required)

By checking here you consent to future correspondence from Wally Moon at the email address you provided.(Required)

What is your gender?(Required)

Male

Female

Are you CURRENTLY taking any prescription medications for weight loss?(Required)

Yes

What is your date of birth? (Must be 18 years or older to qualify)(Required)

YYYY

Please enter a qualifying date of birth.

What is your height and current weight?  (We use this information to calculate your BMI which helps determine treatment qualification)

Feet(Required)

Inches(Required)

This field is hidden when viewing the form

Height in Inches (Calculated)

Lbs(Required)

This field is hidden when viewing the form

BMI (Calculated)

Please enter the best contact phone number to reach you in case one of the doctors has any questions regarding your medical information.(Required)

Can we also send you text messages? (about your prescription, shipment tracking information, or refills)(Required)

Yes

Consent(Required)

By checking this box, I also consent by electronic signature to receive phone calls and/or SMS text messages at the phone number above, including my wireless number if provided. I understand these calls may be generated using an automated technology, pre-recorded voices and that data rates may apply. I understand that my consent is not required to buy goods/services and I may opt out at any time to avoid receiving calls or SMS messages.(Required)

Do any of the following conditions apply to you?(Required)

Currently or possibly pregnant, or actively trying to become pregnant

Breastfeeding or bottle-feeding with breastmilk

End-stage kidney disease (on or about to be on dialysis)

Type 1 or 2 diabetes

Current or prior eating disorder (anorexia/bulimia)

Current suicidal thoughts and/or prior suicidal attempt

Cancer (active diagnosis, active treatment, or in remission or cancer-free for less than 5 continuous years)

History of organ transplant on anti-rejection medication

Severe gastrointestinal condition (gastroparesis, blockage, inflammatory bowel disease)

MI (myocardial infarction) / CVA (cerebrovascular accident) in the past 12 months

Personal or family history of thyroid cyst/nodule, thyroid cancer,medullary thyroid carcinoma, or multiple endocrine neoplasia syndrome type 2

History of or current pancreatitis

Diabetic retinopathy (diabetic eye disease)

None of the above

Consent(Required)

By checking this box, I confirm that the information provided is true, complete, and accurate to the best of my knowledge. I understand that providing false or incomplete information may affect my care.(Required)

NOTE TO FEMALE PATIENTS OF REPRODUCTIVE POTENTIAL IF ‘NONE OF THE ABOVE’ IS SELECTED: Please note that we strongly recommend that you use an effective method of contraception during treatment with a GLP-1 medication and for at least 2 months thereafter. For those taking Zepbound or Mounjaro (tirzepatide), we recommend switching to a non-oral contraceptive method or adding a barrier method of contraception for four weeks after initiation and for four weeks after each dose escalation. For any questions or concerns regarding your specific situation, please speak to your medical provider.

Based on the age, BMI, or potentially the medical conditions you’ve provided us, it appears you don't meet the eligibility criteria for our program. If you think this might be a mistake, please review your submission to ensure all information is correct.

Congratulations , you are qualified.

Please Select Your Treatment.(Required)

Compounded Semaglutide

Semaglutide is a weekly GLP-1 injection that curbs appetite, hunger, and cravings by mimicking your body’s natural processes.

STARTING AT $199 $149*

*Get $50 off with offer code: NEW50

Compounded Tirzepatide

Tirzepatide is the most effective GLP-1 medication for weight loss as it also works on GIP receptors, achieving weight loss even more efficiently.

STARTING AT $299 $249*

*Get $50 off with offer code: NEW50

Please Select 1 Month or 3 Month Bundle then Dose(Required)

1-Month: Starting at $199

3-Month Bundles: Starting at $599

Enter Promo Code at Checkout for Discounted Price

Current Treatment Dose(Required)

1-Month Semaglutide (0.25 mg dose) 2.5mg/ml, 1ml vial for $199

1-Month Semaglutide (0.5 mg dose) 2.5mg/ml, 1ml vial for $249

1-Month Semaglutide (1 mg dose) 2.5mg/ml, 2ml vial for $299

1-Month Semaglutide (1.5 mg dose) 2.5mg/ml, 4ml vial for $299

1-Month Semaglutide (2 mg dose) 2.5mg/ml, 4ml vial for $299

1-Month Semaglutide (2.5 mg dose) 2.5mg/ml, 4ml vial for $299

Current Treatment Dose(Required)

3-Month Maintenance Semaglutide (1 mg dose) Bundle 2.5mg/ml (2x2ml, 1.25ml vial) $599

3-Month Maintenance Semaglutide (1.5 mg dose) Bundle 2.5mg/ml (5ml, 2x1.25 vial) $649

3-Month Maintenance Semaglutide (2 mg dose) Bundle 2.5mg/ml (2x5ml, 0.5ml vial) $699

3-Month Maintenance Semaglutide (2.5 mg dose) Bundle 2.5mg/ml (4x3ml vial) $799

3-Month Titration Semaglutide (0.5,1,1.5 mg doses) Bundle 2.5mg/ml (5ml vial) $599

3-Month Titration Semaglutide (1.5,2,2 mg doses) Bundle 2.5mg/ml (6ml, 1.25ml vial) $649

3-Month Titration Semaglutide (1.5,2,2.5 mg doses) Bundle 2.5mg/ml (2x5ml vial) $699

3-Month Titration Semaglutide (2,2,2.5 mg doses) Bundle 2.5mg/ml (2x5ml, 2ml vial) $799

Select Treatment(Required)

3-Month Bundle: Semaglutide Only $499

Please Select 1 Month or 3 Month Bundle then Dose(Required)

1-Month: Starting at $299

3-Month Bundles: Starting at $799

Enter Promo Code at Checkout for Discounted Price

Current Treatment Dose(Required)

1-Month Tirzepatide (2.5 mg dose) 10 mg, 1 ml vial for $299

1-Month Tirzepatide (5 mg dose) 20 mg, 2 ml vial for $349

1-Month Tirzepatide 30 mg, 3 ml vial (7.5 mg dose) for $399

1-Month Tirzepatide 40 mg, 2 ml vial (10 mg dose) for $449

1-Month Tirzepatide 50 mg, 2.5 ml vial (12.5 mg dose) for $499

1-Month Tirzepatide 60 mg, 3 ml vial (15 mg dose) for $575

Current Treatment Dose(Required)

3-Month Maintenance Tirzepatide (5,7.5,10 mg doses) Bundle 5g/ml $799

3-Month Maintenance Tirzepatide (7.5 mg doses) Bundle 10mg/ml (3x3ml vial) $899

3-Month Maintenance Tirzepatide (10 mg doses) Bundle 15mg/ml (5ml, 3ml vial) $1,199

3-Month Maintenance Tirzepatide (12.5 mg doses) Bundle 15mg/ml (2x5ml vial) $1,299

3-Month Maintenance Tirzepatide (15 mg doses) Bundle 15mg/ml (5ml, 2x3ml vial) $1,499

3-Month Titration Tirzepatide (5,7.5,10 mg doses) Bundle 7.5mg/ml $899

3-Month Titration Tirzepatide (7.5,10,12.5 mg doses) Bundle 10mg/ml $1,199

3-Month Titration Tirzepatide (10,12.5,15 mg doses) Bundle 12.5mg/ml $1,299

3-Month Titration Tirzepatide (12.5,12.5,15 mg doses) Bundle 15mg/ml (4x3ml vial) $1,499

Select Treatment(Required)

3-Month Bundle: Tirzepatide Only $799

Please Select 1 Month or 3 Month Bundle(Required)

1-Month Semaglutide 0.25 mg/week $199

3-Month Bundle Semaglutide 0.25 mg/week $499

Enter Promo Code at Checkout for Discounted Price

Please Select 1 Month or 3 Month Bundle(Required)

1-Month Tirzepatide 2.5 mg/week $299

3-Month Bundle Tirzepatide 2.5 mg/week $799

Enter Promo Code at Checkout for Discounted Price

Company

Treatments

Legal