Medical Weight Loss Program

Welcome to MediDuce Weight Loss & Wellness

Thank you for continuing your weight loss journey with MediDuce! This form is for any and all refill, questions, concerns or changes you would like to make to your program.

Our team will review your submission and respond shortly with next steps if needed! We look forward to supporting you in anyway.

PERSONAL INFORMATION:

First Name *

Last Name *

Phone *

SHIPPING INFORMATION:

Do you need to update your shipping address? *

Yes

Address (Include apartment/unit if applicable)

City

Postal code

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

CURRENT PROGRESS

Previous Weight (weight at program start) *

Current Weight (lbs) *

Goal Weight (lbs) *

Have you experienced any challenges or side effects during your program? *

What month of your program are you currently on? *

Select

Month 2
Month 3
Month 4
Month 5
Month 6
6+ months!
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CURRENT MEDICATION INFORMATION

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

Would you like to change your dosage? *

Yes

New preferred Ozempic/Wegovy/Semaglutide dosage:

0.5 mg

1.0 mg

1.7 mg

2.0 mg

2.4 mg

New preferred Zepbound/Mounjaro/Tirzepatide dosage:

5.0 mg

7.5 mg

10.0 mg

12.5 mg

15.0 mg

Disclaimer: Dosage changes are subject to the provider's evaluation and approval. Any adjustments will be based on your progress, tolerance, and overall health.

ADDITIONAL INFORMATION

Do you have any questions, comments, or feedback about your progress or program? (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) 327-5863

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