Medical Weight Loss Program

Welcome to MediDuce Weight Loss & Wellness

Thank you for choosing MediDuce for your weight loss journey. Please provide your personal details below to get started. Once you complete the intake form, you will be directed to the payment page, followed by a link to schedule your Telehealth consultation with our provider.

Your prescribed medications will be conveniently shipped to your address by our pharmacy partner, and once they arrive, you’ll be ready to begin your program.

PERSONAL INFORMATION:

First Name *

Last Name *

Date Of Birth *

Phone *

Email *

SHIPPING INFORMATION:

Please double-check all the information you provide regarding your address. This is the address we will use to ship your prescribed medications, so ACCURACY IS A MUST.

Address (Include apartment/unit if applicable) *

City *

Postal code *

State (Please put abbreviation ex: CO, AL, OH) *

BODY MEASUREMENT & GOALS

Height (feet) *

Select

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Height (inches) *

Select

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Current Weight (lbs) *

BMI - Auto Calculates

Goal Weight (lbs) *

HEALTH CONDITIONS & MEDICAL HISTORY

Are you currently pregnant? *

Yes

Do you or any family members have a history of Multiple Endocrine Neoplasia (MEN) Syndrome Type II or medullary thyroid cancer? *

Yes

Are you currently being treated for Type 1 or Type 2 Diabetes? *

Yes

CURRENT MEDICATION

Are you currently using any weight loss medications (Ozempic, Wegovy, Zepbound, Mounjaro, etc.)? *

Yes

Which medication are you currently taking?

Ozempic/Wegovy/Semaglutide

Zepbound/Mounjaro/Tirzepatide

What Ozempic/Wegovy/Semaglutide dosage are you currently taking? (mg/week)

0.25

0.5

1.0

1.7

2.0

2.4

What Zepbound/Mounjaro/Tirzepatide dosage are you currently taking? (mg/week)

2.5

5.0

7.5

10.0

12.5

15.0

If you have any comments, questions, or concerns about your weight loss journey, feel free to share them here (optional)

Please ensure all information is accurate before proceeding.

By checking this box I confirm that all information is correct. I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business regarding the program.

(586) 371-6921

[email protected]

3190 Rochester Rd,
Troy, MI 48083, USA