Thank You - Be You Medical

Tell us about your goals(Required)

Please enter your goal.(Required)

Height Foot(Required)

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Height Inches(Required)

Weight lbs(Required)

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Gender (assigned at birth)(Required)

Birthdate(Required)

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Date of Birth

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BMI

(This field is for testing only, will be hidden when form setup is done)

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BMI Category

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Is 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 Comorbidities for BMI between 27 and 29.9(Required)

High Blood Pressure

Type 2 diabetes or prediabetes

High Cholesterol

Obstructive Sleep Apnea

Cardiovascular Disease

Non-Alcoholic Fatty Liver Disease

None of the above

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Show Preventive Use

Beyond Standard Comorbidities 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 cannot 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 muscular 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, 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 next.

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 apply

Do you have any known allergies to medications that have the active ingredients in semaglutide, dulaglutide, or tirzepatide?(Required)

Yes

I don't know

Are you currently taking or have you previously taken any GLP-1 medications(Required)

Yes

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

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)

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Patient State

State(Required)

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Selected 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)

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)

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(Required)

Discount Code

Email(Required)