Weightloss Intake Form

Info Form

Patient Name *

Number *

Address *

Email *

Select Gender *

Date of Birth *

Have you previously taken Semaglutide/Tirzepatide? *

Yes No

Are you taking other medications to treat diabetes, including insulin or sulfonylureas? *

Yes No

Do you have severe problems with your stomach, such as slowed emptying of your stomach (gastroparesis) or problems with digesting foods? *

Yes No

How long has your weight been an issue? *

What methods have you previously tried to lose weight? *

Do you exercise regularly? *

List All Medications you are currently taking (OTC and prescription) *

Please mention any allergies. *

Select Pharmacy Type *

Select Pharmacy Name*

Select Medication Brand *

Select Dosage *

Please mention the name of local pharmacy

Local Pharmacy Address

Local Pharmacy Phone Number

Schedule your Telehealth visit with our provider : *

Upload Prescription

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Do you have any of the following conditions? *

History of medullary thyroid carcinoma *

History of multiple endocrine neoplasia syndrome type 2 (MEN2) *

History of pancreatitis *

History of gallbladder disease *

Women only answer the following questions:

Please check the box if the answer is yes.

Are you pregnant or could you be pregnant? Are you trying for pregnancy or planning for pregnancy soon? Are you on any type of hormone replacement therapy? Are you on any contraceptive methods? Are you breastfeeding? I am a male

Calculate BMI

Weight (lb) *

Height (feet) *

Height (Inches) *

Please Note:

Medications will be shipped directly to patients. You will be consulting with the doctor solely for a prescription.

The consultation fee is $100, payable via Credit Card, CashApp or Zelle.

Please proceed to the next step to enter your billing/shipping details.

How it works

1. Eligibility Check

Complete a simple medical history form so your provider can develop the best treatment plan for you. It's fast, easy, and free.

2. Doctor Review

Speak to a physician or nurse practitioner licensed to treat your condition with a simple online conversation. Follow up with your provider any time you need assistance.

3. Product Delivery

Receive your medication in the mail every month, all programs come with free shipping directly to your door.

Weightloss Intake Form

Info Form

Do you have any of the following conditions? *

Women only answer the following questions:

Calculate BMI

Please Note:

General Consent

Semaglutide & Tirzepatide Injection Consent

How it works

1. Eligibility Check

2. Doctor Review

3. Product Delivery