User Prequalified Form – bondmeds

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MWL Prequalify Form

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What is your current height and weight? (Note: We use this to calculate your BMI).

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Height *

Inch *

Weight *

BMI

How old are you? (Note: Age 65-75 will require an initial sync visit) *

Are you currently taking or have recently (within the last 12 months) taken GLP-1/another medication(s) for weight loss? *

Yes
No

Would you be interested in transitioning your medical weight loss management journey to us? *

Yes
No

Which of the following conditions apply to you? *

None
Currently pregnant or actively trying to become pregnant
Breast-Feeding or Bottle-Feeding with Breast Milk
End-stage Kidney disease (on or about to be on Dialysis)
End-stage Liver disease (Cirrhosis)
Current or prior eating disorder (Anorexia/Bulimia)
Current suicidal thoughts and/or prior suicidal attempt
Cancer (active diagnosis or treatment)
History of organ transplant on anti-rejection medication
Severe gastrointestinal condition (gastroparesis, blockage, IBD)
Type 1 Diabetes
Type 2 Diabetes on Insulin
Diabetic retinopathy (eye condition related to diabetes)
History of or current Pancreatitis
MI/CVA in the past 12 months
Heart attack or stroke within the last 12 months
Hypothyroidism (TSH ≥ 10)
Family or personal history of Medullary Thyroid Cancer (MTC) or Multiple Endocrine Neoplasia Type 2 (MEN2)

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