Ultimate Weightloss Quiz

Weight-Loss Program Smart Intake (≈2–3 minutes)

Name

Are you 18 or older?

Yes No

Stop: “This program is for adults 18+. We can share teen resources.”

What U.S. state will you be located in during telehealth/office visits?

HIPAA/Privacy consent

I consent to submit my information for a weight-management screening and to be contacted by Belfon Health & Aesthetics via SMS/email. Message/data rates may apply. Reply STOP to opt out.

I agree to privacy notice I agree to SMS/email

Medical disclaimer

This screening is not diagnosis or treatment; urgent symptoms require emergency care.

Your goals (engagement first)

What’s your #1 goal right now?

Target weight or clothing size goal

How soon do you want to get started?

Immediately (this week) Within 2–4 weeks Just researching

What’s your biggest obstacle? (Pick up to 2)

About you (auto-calculates eligibility)

Height

Weight

Are you currently pregnant, breastfeeding, or planning to become pregnant?

Which type of health insurance do you have?

Hypertension

Yes No

Do you currently have or ever been diagnosed with any of the following heart related conditions?

Heart Failure Heart rhythym./EKG abnormality Tachycardia or Atrial Fibrillation No, I have not been diagnosed with any of these heart conditions

Do you currently have or have been diagnosed with gastrointestinal conditions or procedures?

Bariatric surgery pancreatitis Gastroparesis/delayed gastric emptying Gallstones/Gallbladder disease GERD/Acid reflux No, I do not have a history of any of these conditions or procedures

Do you currently, or have ever been diagnosed with any of the following conditions?

Bariatric surgery pancreatitis Gastroparesis/delayed gastric emptying Gallstones/Gallbladder disease GERD/Acid reflux No, I do not have a history of any of these conditions or procedures

Before a provider prescribes the medications offered in our office either compounded generic or prescription brand, you will be REQUIRED to speak with them regarding potential risks and benefits of this treatment, alternatives and/or any questions you may have.

Please provide COMPLETE information in order to secure a consultation with our Clinician.

Weight Loss

Welcome to our weight loss consultation services! We understand that achieving and maintaining a healthy weight can be a challenging journey, and we’re here to provide guidance and support along the way.

Our weight loss consultations are designed to help you create a personalized plan that suits your unique needs and goals. Whether you’re looking to shed a few pounds or embark on a significant weight loss journey, our team of experts is here to assist you.

Weight-Loss Program Smart Intake (≈2–3 minutes)

Your goals (engagement first)

About you (auto-calculates eligibility)

Weight Loss

Weight Loss

Receive $50 off your first treatment!

Contact Info

Opening Hours