{"id":1243,"date":"2026-06-05T05:46:29","date_gmt":"2026-06-05T05:46:29","guid":{"rendered":"https:\/\/serenityglowwellness.com\/?page_id=1243"},"modified":"2026-06-10T09:17:57","modified_gmt":"2026-06-10T01:17:57","slug":"glp-1-intake-form","status":"publish","type":"page","link":"https:\/\/serenityglowwellness.com\/es\/glp-1-intake-form\/","title":{"rendered":"GLP-1 Intake Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1243\" class=\"elementor elementor-1243\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-5afb435 e-flex e-con-boxed e-con e-parent\" data-id=\"5afb435\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-98a7236 elementor-widget elementor-widget-shortcode\" data-id=\"98a7236\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var 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#112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/es\/wp-json\/wp\/v2\/pages\/1243#gf_1' data-formid='1' novalidate>\n        <div id='gf_progressbar_wrapper_1' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>6<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_16' style='width:16%;'><span>16%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_3\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p class=\"section-eyebrow\">Getting Started<\/p>\n<h2 class=\"section-heading\">Tell us about <em>yourself<\/em><\/h2>\n<p class=\"section-sub\">This information helps our clinical team prepare for your consultation and confirm telehealth eligibility in your state.<\/p><\/div><div id=\"field_1_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_1'>FIRST NAME<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_1_1' type='text' value='' class='large'    placeholder='First Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_4'>LAST NAME<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='text' value='' class='large'    placeholder='Last Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_5' id='input_1_5' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_5_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_5_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_5' class='gform_hidden' value='https:\/\/serenityglowwellness.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_6\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>SEX ASSIGNED AT BIRTH<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_1_6' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Select' >Select<\/option><option value='Female' >Female<\/option><option value='Male' >Male<\/option><option value='Intersex' >Intersex<\/option><option value='Prefer not to say' >Prefer not to say<\/option><\/select><\/div><\/div><div id=\"field_1_7\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_7'>EMAIL ADDRESS<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_1_7' type='email' value='' class='large'   placeholder='your@email.com' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_8\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_8'>PHONE NUMBER<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_1_8' type='tel' value='' class='large'  placeholder='(555) 000-0000' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_9\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_9'>STATE OF RESIDENCE<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_9' id='input_1_9' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Select your state' >Select your state<\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_60' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='CONTINUE'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-60' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_11\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p class=\"section-eyebrow\">Eligibility Screening<\/p>\n<h2 class=\"section-heading\">Your <em>body metrics<\/em><\/h2>\n<p class=\"section-sub\">GLP-1 therapy requires a BMI of 30 or above, or 27 or above with a qualifying health condition. We'll calculate yours automatically.<\/p><\/div><div id=\"field_1_14\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_14'>HEIGHT - FEET<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_14' id='input_1_14' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='ft' >ft<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><\/select><\/div><\/div><div id=\"field_1_15\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_15'>HEIGHT - INCHES<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_15' id='input_1_15' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='in' >in<\/option><option value='0' >0<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><\/select><\/div><\/div><div id=\"field_1_16\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'>CURRENT WEIGHT (LBS)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_16' id='input_1_16' type='number' step='any'   value='' class='large'    placeholder='lbs' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_50\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full bmi-value gfield_calculation field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_50'>BMI<\/label><div class='ginput_container ginput_container_number'><input name='input_50' id='input_1_50' type='text' step='any'   value='' class='large gform-text-input-reset'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_51\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full bmi-desc gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"bmi-info\">\n        <strong id=\"bmiCategory\">Underweight<\/strong>\n        <span id=\"bmiNote\">GLP-1 therapy may not be appropriate. Our team will review.<\/span>\n      <\/div><\/div><div id=\"field_1_52\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full bmi-desc gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"bmi-info\">\n        <strong id=\"bmiCategory\">Normal weight<\/strong>\n        <span id=\"bmiNote\">GLP-1 eligibility requires BMI \u226527 with a qualifying condition.<\/span>\n      <\/div><\/div><div id=\"field_1_57\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full bmi-desc gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"bmi-info\">\n        <strong id=\"bmiCategory\">Overweight<\/strong>\n        <span id=\"bmiNote\">May qualify with a documented comorbidity (PCOS, hypertension, etc.)<\/span>\n      <\/div><\/div><div id=\"field_1_58\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full bmi-desc gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"bmi-info\">\n        <strong id=\"bmiCategory\">Obese - Class I<\/strong>\n        <span id=\"bmiNote\">Meets standard GLP-1 eligibility criteria.<\/span>\n      <\/div><\/div><div id=\"field_1_59\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full bmi-desc gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"bmi-info\">\n        <strong id=\"bmiCategory\">Obese - Class II\/III<\/strong>\n        <span id=\"bmiNote\">Meets GLP-1 eligibility criteria.<\/span>\n      <\/div><\/div><div id=\"field_1_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_17'>GOAL WEIGHT (LBS)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_1_17' type='text' value='' class='large'    placeholder='lbs' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >WHICH BEST DESCRIBES YOUR PRIMARY GOAL?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_19'>\n\t\t\t<div class='gchoice gchoice_1_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='WEIGHT LOSS &amp; METABOLIC HEALTH'  id='choice_1_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_0' id='label_1_19_0' class='gform-field-label gform-field-label--type-inline'>WEIGHT LOSS &amp; METABOLIC HEALTH<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='PCOS MANAGEMENT'  id='choice_1_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_1' id='label_1_19_1' class='gform-field-label gform-field-label--type-inline'>PCOS MANAGEMENT<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_19_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='HORMONAL BALANCE &amp; WELLNESS'  id='choice_1_19_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_2' id='label_1_19_2' class='gform-field-label gform-field-label--type-inline'>HORMONAL BALANCE &amp; WELLNESS<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_19_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='FERTILITY SUPPORT'  id='choice_1_19_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_3' id='label_1_19_3' class='gform-field-label gform-field-label--type-inline'>FERTILITY SUPPORT<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_61' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='BACK'  \/> <input type='button' id='gform_next_button_1_61' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='CONTINUE'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-61' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_20\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p class=\"section-eyebrow\">Medical History<\/p>\n<h2 class=\"section-heading\">Your <em>health history<\/em><\/h2>\n<p class=\"section-sub\">Please answer honestly \u2014 this helps our clinical team determine the safest protocol for you. Some conditions are contraindications to GLP-1 therapy.<\/p><\/div><fieldset id=\"field_1_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >DO YOU HAVE A PERSONAL OR FAMILY HISTORY OF MEDULLARY THYROID CARCINOMA (MTC) OR MULTIPLE ENDOCRINE NEOPLASIA TYPE 2 (MEN2)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_22'>\n\t\t\t<div class='gchoice gchoice_1_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='NO'  id='choice_1_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_22_0' id='label_1_22_0' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='YES OR UNSURE'  id='choice_1_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_22_1' id='label_1_22_1' class='gform-field-label gform-field-label--type-inline'>YES OR UNSURE<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_47\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"alert-box\">\u26a0\ufe0f Based on your responses, GLP-1 therapy may not be appropriate for you. Our clinical team will review your intake and reach out with personalized guidance.<\/div><\/div><fieldset id=\"field_1_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >HAVE YOU EVER BEEN DIAGNOSED WITH PANCREATITIS?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_23'>\n\t\t\t<div class='gchoice gchoice_1_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='NO'  id='choice_1_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_23_0' id='label_1_23_0' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='YES'  id='choice_1_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_23_1' id='label_1_23_1' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_48\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"alert-box\">\u26a0\ufe0f Based on your responses, GLP-1 therapy may not be appropriate for you. Our clinical team will review your intake and reach out with personalized guidance.<\/div><\/div><fieldset id=\"field_1_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >DO YOU HAVE A HISTORY OF GALLBLADDER DISEASE OR GALLSTONES?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_24'>\n\t\t\t<div class='gchoice gchoice_1_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='NO'  id='choice_1_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_24_0' id='label_1_24_0' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='YES'  id='choice_1_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_24_1' id='label_1_24_1' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >DO YOU HAVE KIDNEY OR LIVER DISEASE?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_25'>\n\t\t\t<div class='gchoice gchoice_1_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='NO'  id='choice_1_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_25_0' id='label_1_25_0' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='YES'  id='choice_1_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_25_1' id='label_1_25_1' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >DO YOU HAVE GASTROPARESIS OR SIGNIFICANT GASTROINTESTINAL (GI) MOTILITY ISSUES?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_26'>\n\t\t\t<div class='gchoice gchoice_1_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='NO'  id='choice_1_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_26_0' id='label_1_26_0' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='YES'  id='choice_1_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_26_1' id='label_1_26_1' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_27\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_2col checks field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >WHICH OF THE FOLLOWING HAVE YOU BEEN DIAGNOSED WITH?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_27'><div class='gchoice gchoice_1_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='HIGH BLOOD PRESSURE'  id='choice_1_27_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_27_1' id='label_1_27_1' class='gform-field-label gform-field-label--type-inline'>HIGH BLOOD PRESSURE<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='TYPE 2 DIABETES \/ PREDIABETES'  id='choice_1_27_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_27_2' id='label_1_27_2' class='gform-field-label gform-field-label--type-inline'>TYPE 2 DIABETES \/ PREDIABETES<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_27_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.3' type='checkbox'  value='PCOS'  id='choice_1_27_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_27_3' id='label_1_27_3' class='gform-field-label gform-field-label--type-inline'>PCOS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_27_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.4' type='checkbox'  value='SLEEP APNEA'  id='choice_1_27_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_27_4' id='label_1_27_4' class='gform-field-label gform-field-label--type-inline'>SLEEP APNEA<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_27_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.5' type='checkbox'  value='HIGH CHOLESTEROL \/ LIPIDS'  id='choice_1_27_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_27_5' id='label_1_27_5' class='gform-field-label gform-field-label--type-inline'>HIGH CHOLESTEROL \/ LIPIDS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_27_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.6' type='checkbox'  value='NONE OF THE ABOVE'  id='choice_1_27_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_27_6' id='label_1_27_6' class='gform-field-label gform-field-label--type-inline'>NONE OF THE ABOVE<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_62' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='BACK'  \/> <input type='button' id='gform_next_button_1_62' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='CONTINUE'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' data-js='page-field-id-62' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_28\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p class=\"section-eyebrow\">Current Medications<\/p>\n<h2 class=\"section-heading\">What are you <em>currently taking?<\/em><\/h2>\n<p class=\"section-sub\">This helps us screen for interactions and personalize your protocol safely.<\/p><\/div><fieldset id=\"field_1_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >ARE YOU CURRENTLY TAKING ANY DIABETES OR WEIGHT LOSS MEDICATIONS?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_29'>\n\t\t\t<div class='gchoice gchoice_1_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='NO'  id='choice_1_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_29_0' id='label_1_29_0' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='YES'  id='choice_1_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_29_1' id='label_1_29_1' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >ARE YOU CURRENTLY TAKING INSULIN?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_30'>\n\t\t\t<div class='gchoice gchoice_1_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='NO'  id='choice_1_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_30_0' id='label_1_30_0' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='YES'  id='choice_1_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_30_1' id='label_1_30_1' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >ARE YOU CURRENTLY TAKING ORAL CONTRACEPTIVES (BIRTH CONTROL PILLS)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_31'>\n\t\t\t<div class='gchoice gchoice_1_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='NO'  id='choice_1_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_31_0' id='label_1_31_0' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='YES'  id='choice_1_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_31_1' id='label_1_31_1' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_33\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_33'>PLEASE LIST ALL CURRENT MEDICATIONS, SUPPLEMENTS, AND DOSAGES.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_33' id='input_1_33' class='textarea small'    placeholder='e.g. Levothyroxine 50mcg, CoQ10 400mg, prenatal vitamins... Write &#039;none&#039; if not applicable.'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_34\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_34'>DO YOU HAVE ANY KNOWN DRUG ALLERGIES?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_1_34' class='textarea small'    placeholder='List any known allergies or write &#039;none&#039;'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_63' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='BACK'  \/> <input type='button' id='gform_next_button_1_63' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='CONTINUE'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_5' class='gform_page' data-js='page-field-id-63' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_35\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p class=\"section-eyebrow\">Reproductive & Hormonal Health<\/p>\n<h2 class=\"section-heading\">Your <em>cycle & fertility<\/em><\/h2>\n<p class=\"section-sub\">This section is unique to our practice. We integrate GLP-1 therapy with your full hormonal picture \u2014 fertility, cycle health, and reproductive goals all matter here.<\/p><\/div><fieldset id=\"field_1_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >ARE YOU CURRENTLY PREGNANT OR BREASTFEEDING?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_36'>\n\t\t\t<div class='gchoice gchoice_1_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='NO'  id='choice_1_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_36_0' id='label_1_36_0' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='YES'  id='choice_1_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_36_1' id='label_1_36_1' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_46\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"alert-box\">GLP-1 medications are not recommended during pregnancy or breastfeeding. Our team will follow up to discuss safe alternatives and support options.<\/div><\/div><fieldset id=\"field_1_37\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >ARE YOU ACTIVELY TRYING TO CONCEIVE (TTC)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_37'>\n\t\t\t<div class='gchoice gchoice_1_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='NO'  id='choice_1_37_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_0' id='label_1_37_0' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='YES - NATURALLY'  id='choice_1_37_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_1' id='label_1_37_1' class='gform-field-label gform-field-label--type-inline'>YES - NATURALLY<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_37_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='YES - IUI'  id='choice_1_37_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_2' id='label_1_37_2' class='gform-field-label gform-field-label--type-inline'>YES - IUI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_37_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='YES - IVF \/ STIMS'  id='choice_1_37_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_3' id='label_1_37_3' class='gform-field-label gform-field-label--type-inline'>YES - IVF \/ STIMS<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >HAVE YOU BEEN DIAGNOSED WITH (PCOS)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_38'>\n\t\t\t<div class='gchoice gchoice_1_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='NO'  id='choice_1_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_38_0' id='label_1_38_0' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='YES'  id='choice_1_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_38_1' id='label_1_38_1' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_38_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='SUSPECTED \/ UNDIAGNOSED'  id='choice_1_38_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_38_2' id='label_1_38_2' class='gform-field-label gform-field-label--type-inline'>SUSPECTED \/ UNDIAGNOSED<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_38_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='NOT SURE'  id='choice_1_38_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_38_3' id='label_1_38_3' class='gform-field-label gform-field-label--type-inline'>NOT SURE<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_39\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >ARE YOU CURRENTLY USING ANY FORM OF HORMONAL CONTRACEPTION?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_39'>\n\t\t\t<div class='gchoice gchoice_1_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='NONE'  id='choice_1_39_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_39_0' id='label_1_39_0' class='gform-field-label gform-field-label--type-inline'>NONE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='ORAL PILL'  id='choice_1_39_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_39_1' id='label_1_39_1' class='gform-field-label gform-field-label--type-inline'>ORAL PILL<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_39_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='HORMONAL IUD'  id='choice_1_39_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_39_2' id='label_1_39_2' class='gform-field-label gform-field-label--type-inline'>HORMONAL IUD<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_39_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='COPPER IUD'  id='choice_1_39_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_39_3' id='label_1_39_3' class='gform-field-label gform-field-label--type-inline'>COPPER IUD<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_39_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='IMPLANT \/ SHOT'  id='choice_1_39_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_39_4' id='label_1_39_4' class='gform-field-label gform-field-label--type-inline'>IMPLANT \/ SHOT<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_39_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='OTHER'  id='choice_1_39_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_39_5' id='label_1_39_5' class='gform-field-label gform-field-label--type-inline'>OTHER<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_40\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_40'>DATE OF LAST MENSTRUAL PERIOD<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_40' id='input_1_40' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_40_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_40_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_40' class='gform_hidden' value='https:\/\/serenityglowwellness.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_41\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_41'>TYPICAL CYCLE LENGTH<\/label><div class='ginput_container ginput_container_select'><select name='input_41' id='input_1_41' class='large gfield_select'     aria-invalid=\"false\" ><option value='Select' >Select<\/option><option value='21-24 days' >21-24 days<\/option><option value='25-30 days' >25-30 days<\/option><option value='31-35 days' >31-35 days<\/option><option value='36+ days (irregular)' >36+ days (irregular)<\/option><option value='No period \/ amenorrhea' >No period \/ amenorrhea<\/option><\/select><\/div><\/div><div id=\"field_1_42\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_42'>PREVIOUS WEIGHT LOSS ATTEMPTS \u2014 WHAT HAVE YOU TRIED?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_42' id='input_1_42' class='textarea small'    placeholder='e.g. dieting, previous medications, bariatric surgery, other programs...'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_64' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='BACK'  \/> <input type='button' id='gform_next_button_1_64' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='CONTINUE'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_6' class='gform_page' data-js='page-field-id-64' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_43\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p class=\"section-eyebrow\">Almost Done<\/p>\n<h2 class=\"section-heading\">Review & <em>consent<\/em><\/h2>\n<p class=\"section-sub\">Please read and acknowledge each item below before submitting your intake form.<\/p><\/div><div id=\"field_1_44\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"info-box\">By submitting this form you are not yet enrolled in a program. A member of our clinical team will review your intake and reach out within 1\u20132 business days.<\/div><\/div><fieldset id=\"field_1_45\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox _vertical gfield--width-full consent-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_45'><div class='gchoice gchoice_1_45_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.1' type='checkbox'  value='I understand that &lt;strong&gt;compounded GLP-1 medications are not FDA-approved finished drug products&lt;\/strong&gt; and are prepared by licensed compounding pharmacies for patients with documented clinical need.'  id='choice_1_45_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_45_1' id='label_1_45_1' class='gform-field-label gform-field-label--type-inline'>I understand that <strong>compounded GLP-1 medications are not FDA-approved finished drug products<\/strong> and are prepared by licensed compounding pharmacies for patients with documented clinical need.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_45_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.2' type='checkbox'  value='I confirm that I am &lt;strong&gt;not currently pregnant or breastfeeding&lt;\/strong&gt;, and I am not planning to become pregnant within the next 2 months.'  id='choice_1_45_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_45_2' id='label_1_45_2' class='gform-field-label gform-field-label--type-inline'>I confirm that I am <strong>not currently pregnant or breastfeeding<\/strong>, and I am not planning to become pregnant within the next 2 months.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_45_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.3' type='checkbox'  value='I agree to &lt;strong&gt;monthly check-ins&lt;\/strong&gt; with the Serenity Glow &amp; Wellness clinical team and to report any significant side effects promptly.'  id='choice_1_45_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_45_3' id='label_1_45_3' class='gform-field-label gform-field-label--type-inline'>I agree to <strong>monthly check-ins<\/strong> with the Serenity Glow &amp; Wellness clinical team and to report any significant side effects promptly.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_45_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.4' type='checkbox'  value='I understand that my information will be reviewed by a licensed provider and that &lt;strong&gt;a prescription is not guaranteed&lt;\/strong&gt;. Eligibility is determined at the clinical team&#039;s discretion.'  id='choice_1_45_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_45_4' id='label_1_45_4' class='gform-field-label gform-field-label--type-inline'>I understand that my information will be reviewed by a licensed provider and that <strong>a prescription is not guaranteed<\/strong>. Eligibility is determined at the clinical team's discretion.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_45_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.5' type='checkbox'  value='I have provided &lt;strong&gt;accurate and complete information&lt;\/strong&gt; to the best of my knowledge. I understand that withholding relevant medical history may affect my safety and care.'  id='choice_1_45_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_45_5' id='label_1_45_5' class='gform-field-label gform-field-label--type-inline'>I have provided <strong>accurate and complete information<\/strong> to the best of my knowledge. 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