Step 1 of 13 7% Tell us about your goals(Required)Lose a handful of stubborn lbs (fewer than 20lbs)Lose a significant amount of weight (20lbs or more)Maintain my weight loss. I have already lost most of the weight I needed to lose but have struggled to keep it off in the pastImprove my heart health. or other underlying medical conditions I believe GLP-1 medications help withOther goal not listed herePlease enter your goal.(Required) Height Foot(Required)Please enter a number greater than or equal to 0.Height Inches(Required)Weight lbs(Required)Please enter a number greater than or equal to 0.Gender (assigned at birth)(Required)MaleFemaleBirthdate(Required) MM slash DD slash YYYY HiddenDate of Birth HiddenBMI(This field is for testing only, will be hidden when form setup is done)HiddenBMI Category HiddenIs GLP-1 Valid My Current Weight Expected Weight Loss *In clinical trials, participants with a BMI of 27 or higher had average weight loss of 15% with semaglutide injections and 20% with tirzepatide injections, when combined with diet and exercise. Standard Commorbidities for BMI between 27 and 29.9(Required) Comorbidity 1 Comorbidity 2 Comorbidity 3 None of the above HiddenShow Preventive Use Beyond Standard Commorbidities and Preventive Use (Early Intervention)(Required) Pre-Diabetes or high risk of developing type 2 diabetes or insulin resistance Cardiovascular risk: family history or other risk factors Metabolic syndrome None of the above Beyond Standard Weight Management + Appetite Control + Body Composition(Required) Exercise Regularly and eat healthy just cant seem to get to what feels like a healthy weight Exercise and/or diet is inconsistent due to demanding schedule which is unavoidable at my current stage of life Yo-yo up and down due to appetite control issues or feelings of a lack of will power I categorize myself as a skinny fat person. I have never been very muscalar so my actual weight does not accurately represent how much fat I really need to lose. None of the above Weight Management Needs for the overweight but not obese (25-29.9) Based on the information you provided, you are not eligible to be prescribed GLP-1 medications, if you believe some of the information you provide was not accurate, you may start over by clicking "Start Over" or if you would like continue and schedule a call with one of our providers, even understanding that you are more than likely not eligible for GLP-1 medications you may do so by clicking continue. Good News! It appears as though you might be a perfect candidate for GLP-1 medication. We need to gather a little more info to confirm. Let's make sure you don't have any of the following conditions:(Required) MTC MEN 2 Active Cancer Active Drug or Alcohol Misuse Eating Disorder Bipolar Disorder Schizophrenia Pancreatitis Diabetes Mellitus Type 1 Any Liver or Kidney Disease Active Gallbladder Disease Chronic or persistent hypoclycemia with ranges , 60 mg/dl Pregnant or planning to become pregnant in the next 2 months None of the above Select all that applyDo you have any known allergies to medications that have the active ingredients in semaglutide, dulaglutide, or tirzepatide?(Required) Yes No I don't know Are you currently taking or have you previously taken any GLP-1 medications(Required) Yes No Great! So you are already somewhat familiar with the benefits of GLP-1 medications. Which of the following medications have you used?(Required) Compounded Semaglutide Compounded Tirzepatide Ozempic, Wegovy Mounjaro, Zepbound Rybelsus Other Is there a specific GLP-1 medication you were hoping to have prescribed, or do you trust the doctor to make the decision based on your medical history?(Required) Compounded Semaglutide Compounded Tirzepatide Ozempic, Wegovy Mounjaro, Zepbound Rybelsus Other I trust the doctor’s recommendation Which other GLP-1 medications have you taken?(Required) What other GLP-1 medications are you hoping to have prescribed to you?(Required) What was the approximate date of your last dose?(Required) How many mg was your last dose?(Required) Would you like another prescription of the same medication and the same dose?(Required) Yes No Please describe the medication and dose you are hoping to be prescribed.(Required) Do you currently take any of the following medications?(Required) DPP-4 Inhibitors such as sitagliptin and saxagliptin Sulfonylureas such as (but not limited to) glipizide... Insulin Warfarin (also called Jantoven or Coumadin) Meglitinides such as repaglinide or nateglinide Diuretics such as (but not limited to) furosemide (Lasix), bumetanide (Bumex) Hydrochlorothiazide/HCTZ Selective Serotonin Reuptake Inhibitor (SSRI) such as (but not limited to) citalopram (Celexa), fluoxetine (Prozac), escitalopram (Lexapro) I don't take any of these medications Great News! Based on the information you provided you are eligible to begin taking GLP-1 medication! Let's gather some final information to complete your patient profile! First Name(Required) Last Name(Required) HiddenPatient StateState that allows asynchronous interaction for approvalState that allows phone and video but not asynchronousState that requires video visit intial visitState(Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaWashingtonWest VirginiaWisconsinWyomingHiddenSelected State Awesome! Your state allows you to have prescription medications approved and prescribed without the need to be seen by your doctor! Instead, one of our providers licensed in your state will review the information on the medical intake form you have already completed and approve your prescription without an appointment. They will then send your prescription to our pharmacy network to be filled and cold shipped overnight directly to your preferred address. Its really that simple! However, if you would still prefer to speak to one of our providers first you are absolutely able to do so by selecting either video visit or phone visit below. If you you choose to have a phone call or a video visit with the provider your next step will be to schedule the call based on their availability, If you choose to get approved based on our provider's review of your medical intake form information, there is no need to schedule an appointment and your prescription, if approved, will be written and sent to the pharmacy for processing within 24hrs. How would you like to proceed?(Required)Have the provider approve my GLP-1 prescription based on my medical intake form (Quickest Option)Schedule of phone or video call with the Provider (2nd Quickest Option)What do you prefer?(Required) Video Call Phone Call Nice! Your state allows you to have prescription medications approved and prescribed without the need to be seen in-person by your doctor! Instead, one of our providers licensed in your state will be able to approve your prescription with a simple phone visit. Once approved, they will then send your prescription to our pharmacy network to be filled and cold shipped overnight directly to your preferred address. It's really that simple! However, if you would prefer to speak to one of our providers over live video rather than just having a simple phone call, you are absolutely able to do so by selecting video visit below. How would you like to proceed?(Required)Schedule of phone call with the Provider (Quickest Option)Schedule a Video Visit with the provider (Slowest Option) Your state requires all patients to have a video visit with a licensed provider in order to have their initial prescription approved. Let's get you scheduled! Perfect! Let's finish up with your shipping and payment info. Just so we're clear, your payment method will not be charged until your prescription is approved and sent to the pharmacy! Shipping Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone Discount Code Email(Required)