Weight Loss Goals Form Step 1 of 4 25% Name(Required) First Last Email(Required) Enter Email Confirm Email AgePlease enter a number from 18 to 120. Health AnalysisThis field is hidden when viewing the formWhich weight measurement are you most familiar with KG - Kilograms LBS - Pounds Current Weight (kg)Target/Goal Weight (kg)Height (cm)Do you have any known medical conditions? Yes No Known Medical ConditionsPlease list them separated with a commaAre you currently taking any medications? Yes No Which medications?Please list them separated with a commaHave you used semaglutide or any weight loss injections before? Yes No Any allergies or hypersensitivities? Yes No Please specify your allergies or hypersensitivitiesPlease list them separated with a comma Weight GoalsWhy do you want to lose weight? To feel more confident To improve my health To look better in clothes To be more attractive To boost self-esteem For a special event (e.g., wedding, reunion, vacation) To gain control over my body I’ve struggled with weight for years I want to prove to myself I can do it Others Please specify other reasonsWhat are your goals beyond the number on the scale?(Optional short answer) Example: I want to feel sexy again, fit into my old clothes, or wear a swimsuit confidently.How serious are you about reaching your goal weight? Very serious – I’m ready to commit I want results but need guidance Just exploring for now Final QuestionsWhich Plan are you inquiring about? 3 Month Plan - Entire Vial of Semaglutide 1 Month Plan - 4x a month visitation Trial Only - 1 Visit The 3 Month plan costs: ₱22,950.00 Original price was: ₱22,950.00.₱14,880.00Current price is: ₱14,880.00.The 1 Month plan costs: ₱7,120.00The Single Visit costs: ₱2,160.00How do you want to receive it? Pickup (in-store) Delivery (add ₱300 shipping fee) Preferred date/time of pickup or deliveryAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Payment Method Cash (in-store) Credit/Debit Card (in-store) Credit/Debit Card (online payment with Maya) GCash or Bank Transfer Consent• I understand that semaglutide works best when paired with a healthy lifestyle. • I acknowledge that I am choosing to use semaglutide and understand how it supports my weight loss journey. • I acknowledge that I am choosing to use semaglutide and understand how it supports my weight loss journey.
