Select Your Gender

Enter your full name*

Enter your Phone Number*

Enter your Email Address *

Enter your Address*

Enter your Date of Birth*

What's your Instagram name?*

Goals has partnered with Quest Diagnostic Laboratories to provide convenient lab testing for MediFlex program patients. Will you be able to visit a Quest Diagnostics location for your bloodwork? *

If you would like to use your insurance to pay for your bloodwork, please upload a photo of the front and back of your insurance card.

Initial Health Assessment

Please answer the following questions

Are you in good health?*

Are you currently under the care of a physician?*

Have you been hospitalized or had a serious illness within the last five (5) years?*

What is your height?*

What is your current body weight?*

What is the most you have weighed and what year was this?*

What is the least you have weighed and what year was this?*

What weight loss methods have been successful for you in the past?*

What are your current eating habits?*

Do you have any of the following health conditions?*

Do you have any drug allergies?*

Do you have medullary thyroid cancer or a history of medullary thyroid cancer?*

Please list all or any of your medical conditions*

Please list your current medications.*