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Personalized Weight Loss & Peptide Therapy

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Guided by a Licensed Provider.

Tell us about your goals and health history, and our team will follow up to schedule your one-on-one consultation. No treatment is prescribed from this form alone — every plan starts with a provider evaluation.

Licensed Nurse Practitioner–Led Care

In-Person Clinic in South Miami

Individualized Treatment Plans

Consultation Required Before Any Prescription

Two Paths, One Form

This page serves patients interested in either medically supervised weight loss (GLP-1 medications) or peptide therapy — or both. Select an interest below and the right follow-up questions will appear.

Weight Loss / GLP-1

Semaglutide & tirzepatide-based programs, paired with lab work and provider follow-up. Individual results vary.

Peptide Therapy

Physician-directed peptide protocols to support recovery, sleep, and wellness goals as part of an individualized plan.
Some medications and peptides discussed on this page are compounded and/or used off-label under the guidance of a licensed provider and may not be FDA-approved for this specific use. This form is for informational and scheduling purposes only and does not constitute a prescription, diagnosis, or medical advice.

Patient Interest & Health Questionnaire

    Contact Information

    Required for every submission.

    First Name

    Last Name

    Date of Birth(Must be 18+)

    Phone Number

    Email Address

    Preferred Contact Method

    City / Zip Code(Confirm you're in our South Florida service area)

    What Are You Interested In?

    This selection controls which questions appear next.

    General Health History

    Shown for all patients, regardless of interest selected.

    Current Medications & Supplements

    Known Drug or Medication Allergies

    Known Drug or Medication Allergies

    Weight Loss Details

    Height

    Current Weight (lbs)

    Goal Weight or Goal (optional)

    Have you used GLP-1 medications before (Ozempic, Wegovy, Mounjaro, or compounded semaglutide/tirzepatide)?

    Other weight-loss programs or medications you've tried

    Peptide Therapy Details

    What are you hoping to address? (Select all that apply)

    Have you used peptide therapy before?

    Relevant injury, condition, or context your provider should know

    Provider Guidance

    Tell Us What You’re Hoping to Achieve

    Consent & Acknowledgment

    Type Full Name as E-Signature

    Date(This field is automatically populated with today’s date.)

    A FIXX Wellness team member will contact you within 1 business day to schedule your consultation.

    Empower

    Empower Pharmacy
    7601 N Sam Houston Pkwy W, Ste 100
    Houston, TX 77064
    (877) 562-8577

    Olympia Pharmaceuticals

    Olympia Pharmaceuticals
    6700 Conroy Windermere Rd, Ste. 155
    Orlando, FL 32835
    (800) 991-9079

    Belmar

    Belmar Pharmacy
    12860 West Cedar Drive, Suite 211
    Lakewood, CO 80228
    (877) 267-3410