Name *

First Name

Last Name

Phone *

Enter your number and we'll give you a call.

(###)

###

####

DOB *

MM

DD

YYYY

Illnesses/problems of the liver *

Yes

No

Illnesses/problems of the kidney *

Yes

No

Heart failure *

Yes

No

Obesity secondary to endocrinological issues *

Yes

No

Inflammatory bowel disease *

Yes

No

Diabetic gastroparesis *

Yes

No

Thyroid disease *

Yes

No

Have you ever had a problem with your pancreas, including pancreatitis? *

Yes

No

Do you suffer from an existing eating disorder? *

Yes

No

Are you hypersensitive (allergic) to liraglutide? *

Yes

No

Are you pregnant, think you might be pregnant, planning to have a baby or currently breastfeeding? *

Yes

No

Are you currently on treatment with GLP1-RA, e.g., Victoza? *

Yes

No