Luxe Med New Patient Intake

Luxe Med Patient Intake and Health History
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Full Name
Please enter your height.
Please enter your weight.
Allergies (check all that apply)
Select all allergies that apply to you.
Health Conditions (check all that apply)
Select all that apply to your medical history.
Are you currently pregnant?
Are you currently breastfeeding?
Please indicate the reasons you think are contributing to having excess weight
What methods and/or interventions have you tried in the past?

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Treatment Process

  • Registration ($100 fee) includes all appointments (e-consultation or phone consultation), shipping, and supplies for the program.
  • Invoices for the registration fee, questionnaire, and consent forms will be emailed.
  • Program payment invoice will be sent.
  • Injections will be ordered, and dosage and administration instructions will be provided via email.
  • A progress appointment will be scheduled (e-consultation or phone consultation) three weeks later to go over your results and determine next steps in your transformation.

Getting Started

This weight loss program is offered on a monthly basis. A provider will prescribe Semaglutide or Tirzepatide and guide you on how to self-administer the injections at home.

Treatment Process

  • Registration ($100 fee) includes all appointments (e-consultation or phone consultation), lab work, shipping, and supplies for the program.
  • Invoices for the registration fee, weight loss questionnaire, and consent forms will be emailed.
  • Bloodwork will be ordered through Quest Diagnostics once forms are submitted and the deposit is paid.
  • Lab results and the program payment invoice will be sent.
  • Medication will be ordered, and dosage and administration instructions will be provided via email.
  • A progress appointment will be scheduled (e-consultation or phone consultation) three weeks later to go over your results and determine next steps in your transformation.