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To get started, we need to calculate your BMI

Please enter your height and weight below.

Height *

Weight (lb) *

Are you over 18 years old?

*Neo Soma providers specialize in medically supervised weight loss for adults. Please see your primary care physician if under the age of 18.

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Do you already have an account with us? *

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Please select your gender *

Male
Female

Please Select Your State *

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Name *

First

Last

Email *

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Password *

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Phone Number *

Date of Birth *

Race *

Marital Status *

Please upload a photo of your drivers license *

Click or drag a file to this area to upload.

What is your primary goal for weight loss treatment? *

I want to improve my quality of life
I want to treat or reverse complications related to obesity
I want to prevent complications related to obesity

Please select all that apply.

How much weight would you like to lose over the next 3 months? *

Have you ever taken weight loss medication? *

l am currently on a weight loss medication
l stopped taking my weight loss medication
l have NEVER been on a weight loss medication

Weight Reduction & Safety Disclosure*

Weight Reduction & Safety Disclosure Item 1 *

I understand that weight loss medication DOES NOT guarantee weight loss, especially if I do not use the Rx along with a healthy diet and exercise.

Weight Reduction & Safety Disclosure Item 2 *

I DO NOT hold Neo Soma responsible for lack of weight loss success.

Weight Reduction & Safety Disclosure Item 3 *

I understand that weight loss treatment is only one part of my weight loss plan to help me reach my goals. I understand that I also need a reduced calorie diet and increased physical activity for chronic weight management.

Weight Reduction & Safety Disclosure Item 4 *

I have been informed that weight loss prescriptions are contraindicated in pregnancy or nursing women.

Weight Reduction & Safety Disclosure Item 5 *

I understand that weight loss prescriptions can cause side effects such as: facial swelling, feeling faint or dizzy, trouble breathing or swallowing, rapid heartbeat or severe rash and itching. I acknowledge the following risks of taking weight.

Do you have any of the following weight-related conditions? *

Hypertension
Type 2 Diabetes
High cholesterol or dyslipidemia
Sleep apnea
Fatty Liver
None, I DO NOT have any of the conditions listed above

Please select all that apply.

What is your average blood pressure reading? *

Normal (Lower than 140/100)
Elevated (Less than 150/100)
Uncontrolled (Over 170/100)

Do you or your family have a history of medullary thyroid carcinoma? *

HOLD UP! You cannot take this medication due to your personal or family history of medullary thyroid carcinoma.

Which of these conditions are you presently experiencing? *

Liver disease or Kidney diseases
Acute pancreatitis or acute gallbladder diseases
Multiple Endocrine Neoplasia Syndrome
None of the conditions above

Please select all that apply.

HOLD UP! You're not a candidate for online treatment due to the severity of your symptoms. Please visit a doctor.

Which of the following have you tried to lose weight? *

Diet
Exercise
Portion Control or calorie counting
Weight loss supplements
Weight loss Apps
Bariatric surgery
Liposuction
Behavior therapy by a trained professional
Acupuncture
None of the weight loss measures listed above

Please select all that apply.

Please Watch The Entire Video Before Proceding

Video Confirmation 1 *

I confirm that I watched the entire video presented to me.

Prescription Refill Agreement*

Prescription Refill Agreement *

I understand that Neo Soma will prescribe a one month supply of my weight loss prescription at a time. I understand I will need to follow up with the clinic every month for re-evaluation and refills.

Prescription Return & Refund Agreement *

I understand medications are not returnable or refundable under any circumstances.

Are you allergic to any drug? *

No drug allergies
Yes

Please list out the drugs you're allergic to *

Select the underlying medical conditions you have *

None, I do NOT have any chronic medical or psychiatric conditions
Heart disease
Hypertension
Liver disease
Kidney disease
Diabetes
High cholesterol
Thyroid disorder
Psychiatric condition
HIV/AIDS
Other Condition

Please select all that apply.

Please list out the other medical conditions you have *

Are you currently taking any medication? *

This includes any over the counter drugs or supplements.

Please list out the medications you're taking *

Medication Disclosure Clause*

Medication Disclosure Clause No Medication *

I hereby certify that I am currently taking other medication that may include OTC or supplements, and agree to indemnify and hold Neo Soma Healthcare and its employees harmless from any loss, damages, liability, legal liability and expenses resulting from withholding or non-disclosure of my medication or any other vital medical information.

Medication Disclosure Clause With Medication *

I hereby certify that I am currently taking other medication that may include OTC or supplements, and agree to indemnify and hold Neo Soma Healthcare and its employees harmless from any loss, damages, liability, legal liability and expenses resulting from withholding or non-disclosure of my medication or any other vital medical information.

Please select all applicable surgical history *

None, No surgical past
Appendectomy
Breast augmentation
C-section
Gallbladder surgery
Hysterectomy
Hernia repair
Mastectomy
Orthopedic surgery
Tonsillectomy
Other surgery

Please select all that apply.

Please list out the other surgical procedures you've received *

Which of these Social Histories apply to you? *

I drink coffee or caffeinated drinks regularly
Current smoker (Vape, cigarette or tobacco)
Former cigarette or tobacco use
Marijuana use
Opioid Addiction
Alcohol Addiction
Recreational or illicit drug use
None of the above

Please select all that apply.

When was your last in-person visit to the doctor office? *

In the last 3 months
In the last 3 to 6 months
In the last 6 to 12 months
Over a year ago
NEVER see a doctor in-person

Given the limitation of telemedicine, we encourage an in-person follow-up if your medical concerns do not resolve after a telemedicine visit. *

I agree to follow-up for an in-person re-evaluation with a local doctor as needed
I have an upcoming appointment with my doctor

Informed Consent and Authorization to Administer Treatment*

Informed Consent and Authorization to Administer Treatment 1 *

I hereby authorize Neo Soma's medical team to review my medical history and administer medical services to me, the patient, via telemedicine (synchronous or asynchronous)

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Weight Reduction & Safety Disclosure*

Please Watch The Entire Video Before Proceding

Prescription Refill Agreement*

Medication Disclosure Clause*

Informed Consent and Authorization to Administer Treatment*

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