GS-05-Male-OT - CureWeight

Please enter your first and last name.

First Name

Last Name

Please enter the email where we can send appointment reminders and updates.

Email

Please select the country you will be located for your doctor appointment. This should be the country on your government issued ID.

Country

Please enter your current and goal weight.

Current Weight

Goal Weight

How tall are you?

Height (cm)

What is your birth date?

Date of Birth

Please let us know your weight loss concerns.
Check all that apply.

Have you used any weight loss medications before?
Check all that apply.

Have any of your family members been diagnosed with the following conditions?
Check all that apply.

Family History

Have you ever had Bariatric Surgery?
Gastric bypass, gastric balloon, sleeve gastrectomy, or other.

Bariatric Surgery

Yes No

Have you ever had any of the following conditions?
Check all that apply.

Have you ever been diagnosed with any of the following?
Check all that apply.

Other Conditions

Have you ever had an allergic reaction to any medications?

Allergies_Yes

Yes

Allergies

Allergies_No

No Allergies