Weight Loss Journey – SlimRx Center

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- Step 1 of 9

What is your name? *

First

Last

Which state do you live in?

Let's ensure you're paired with a licensed provider certified in your state.

Address Line 1

City

State

What is your date of birth?

You must be 18 years of age in order to participate in our weight loss program

Date of birth *

Let's calculate your Body Mass Index (BMI)

Weight *

Height *

What is your gender? *

Male
Female
Prefer not to answer

Whar's your phone number? *

Whar's your email? *

Are you currently diagnosed with any of the following conditions?

None
High blood pressure
High cholesterol
Pre-diabetes
Type II diabetes
Joint pain
Sleep apnea
Fatty liver
Back pain
Arthritis
Hypertension
PCOS

Have you ever been diagnosed with, or treated for, any of the following medical conditions?

None
Undergoing dialysis
Kidney transplant
Stroke
Hart failure
Heart transplant
Active cancer undergoing treatment
Pancreatitis
Psychosis, schizophrenia, or schizoaffective disorder
Anorexia or bulimia
Liver failure
History of Thyroid Cancer

Some of these conditions may put people at increased risk for health complications. Make sure to scroll all the way down and answer carefully. If none apply select None.

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