Application - Omni Health

Metabolic Management Application — Omni Health

Program Fit Goals Clinical Service Alignment Final Review

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Program Fit

Let us start with the basics. All information submitted here is kept strictly confidential and used solely to evaluate your fit for care.

First Name * Please enter your first name.

Last Name * Please enter your last name.

Email Address * Please enter a valid email address.

Mobile Number * Digits only — formats automatically. Please enter a valid 10-digit US phone number.

Date of Birth * Type digits — slashes added automatically. Must be 18+. Please enter a valid date of birth.

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Age requirement not met Omni Health services are available to adults 18 and older. We are unable to process this application.

State of Residence * Services available in NY, CT, and WA. Please select your state of residence.

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Service not available in your state We currently provide telehealth services in New York, Connecticut, and Washington.

City * Please enter your city.

How did you hear about Omni Health?

Decision Context

Where are you in your process? *

I have not started any intervention and want clarity before deciding I am currently receiving an intervention and want evaluation or refinement I have completed or paused an intervention and want help understanding results I am seeking a clinical evaluation or second opinion and am not currently pursuing any intervention

Please select an option.

What question or decision would you like clarity on? * Please provide details.

What prompted you to apply now? * Please share what prompted your application.

What outcomes are you hoping to achieve over the next 6-12 months? * Please describe your goals.

What has felt missing from prior weight-loss or metabolic care?

Priority Focus Areas

Which areas matter most to you right now? *

Fat loss / body composition Appetite regulation / food noise Medication tolerance / side-effect reduction Nutrition structure / macros Behavioral support Hormonal / metabolic optimization Long-term maintenance

Please select at least one priority area.

Baseline Measurements

Height — Feet * Enter feet (3-7).

Height — Inches * Enter inches (0-11).

Current Weight (lbs) * Enter your weight in lbs.

Body Mass Index (calculated)

BMI —

Enter height and weight above to calculate your BMI.

GLP-1 History

Have you previously used a GLP-1 or similar weight-loss medication? *

Yes No

Please select an option.

Lab Work

Have you had lab work completed within the last 3 months? *

Yes No

Please select an option.

Can you provide those results through the secure intake form? *

Yes No

CBC, CMP, HbA1c, fasting lipids, TSH, fasting insulin, and other relevant results. Please select an option.

Do you have a preference for where you get your labs done? * We will provide a lab order. Most results are back within 1-3 business days.

Quest Diagnostics Labcorp Other / No preference

Please select a lab preference.

GLP-1 Pathway Review

Do you have a personal or family history of medullary thyroid carcinoma (MTC) or MEN2? *

Yes No

Please answer this question.

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GLP-1 pathway note Your response requires clinical review. You may still be considered for non-pharmacologic care pathways.

Are you currently pregnant, trying to conceive, or breastfeeding? *

Yes No

Please answer this question.

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GLP-1 pathway is not appropriate Your submission can still be reviewed for other care pathways where appropriate.

Conditions Requiring Clinical Review

Do you have a history of pancreatitis? *

Yes No

Please answer this question.

Do you have a history of gastroparesis or significant delayed gastric emptying? *

Yes No

Please answer this question.

Are you planning a surgical procedure or colonoscopy within the next 4 weeks? * If yes, we will discuss timing of GLP-1 initiation, if applicable, before proceeding.

Yes No

Please answer this question.

Medical History

Please select any conditions that apply to you. *

Crohn’s Disease Ulcerative Colitis Pheochromocytoma Type 1 Diabetes Type 2 Diabetes Pre-Diabetes Gallbladder Disease Gallstones Active Eating Disorder High Cholesterol High Blood Pressure Liver Disease Kidney Disease Joint Pain / Osteoarthritis Sleep Apnea PCOS Colostomy / Major GI Surgery History of Bariatric Surgery Anxiety Depression Emotional Eating Food Noise Thyroid Disease Parathyroid Hyperplasia None of the above

Please make a selection, or choose None of the above.

What type of support are you looking for? *

One-time expert assessmentComprehensive metabolic evaluation and clinical recommendation — no ongoing commitment. Structured short-term programA defined program with expert oversight, monitoring, and a personalized plan. High-touch concierge longitudinal care24/7 clinician access, weekly recalibration, and elite clinical oversight across the full course of treatment. Not sure yet — I would like guidance.

Please make a selection.

Services of Interest

Which services are you most interested in? *

Medical weight loss (GLP-1 or other) GLP-1-only optimization Non-medical metabolic support Personalized nutrition Behavioral support

Please select at least one service.

Readiness and Expectations

How ready are you to follow a structured plan? *

Fully ready Mostly ready Somewhat ready Not sure

Please select an option.

What level of support do you expect from your clinician between visits? *

Minimal — I prefer to work independently between sessions. Moderate — periodic check-ins and guidance when needed. High — I want close accountability and responsive support.

Please select an option.

When are you hoping to begin? *

As soon as possible Within 2-4 weeks Within 1-3 months Just exploring options

Please select an option.

Which best describes your approach when selecting care? *

I am looking for the best clinical fit and highest level of support. I want a strong balance of clinical value and investment. Cost is my primary deciding factor.

Please select an option.

Submission of this application does not establish a patient-provider relationship and is for informational purposes only. Omni Health reserves the right to decline any application at its sole clinical discretion.

Is there anything else you would like us to know before review?

Acknowledgment

Please confirm the following before submitting. *

I understand that submission of this application does not establish a patient-provider relationship. I acknowledge that Omni Health will review my application and contact me with next steps. I consent to being contacted at the email and phone number I have provided.

Please acknowledge the above before submitting.

Application Received

Based on your responses, you appear to be a candidate for care.

Questions? Email us at connect@omnihealth.live

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