See If You Qualify

Full Name *

Date of Birth *

Sex Assigned at Birth *

Sex Assigned at Birth

Height *

Weight *

Allergies to Medications *

Current medications & supplements *

Phone *

Email *

State you’re physically located in *

Street Address *

City *

Postal Code *

Weight Loss (GLP-1 programs)

Goal Weight *

Previous weight loss attempts *

History of:

Consent & Acknowledgements

Not Emergency Care *

I understand that this service is not intended for emergency or urgent medical care. If I am experiencing a medical emergency, I agree to call 911 or seek immediate in-person medical attention.

Subscription Billing Agreement *

I understand and agree that this program operates on a subscription billing model. I authorize recurring charges according to the plan I select, and I understand I may cancel according to the program’s stated cancellation policy.

Consent to Asynchronous Provider Review *

I consent to an asynchronous review of my information by a licensed medical provider, meaning I may not interact with the provider in real time before a treatment decision is made.

Telehealth Limitations *

I understand that this service is provided via telehealth and does not replace an in-person medical visit. I acknowledge that telehealth has limitations and that certain conditions may require in-person evaluation.

Legal Protection & Expectations *

I confirm that the information I have provided is true, accurate, and complete to the best of my knowledge. I understand that providing inaccurate or incomplete information may affect my eligibility for services or treatment recommendations.

Pharmacy Fulfillment Consent *

I consent to the sharing of my relevant health information with a licensed pharmacy for the purpose of prescription fulfillment and medication delivery, if approved by a medical provider.

See If You Qualify

Medical History & Safety Screening

Weight Loss (GLP-1 programs)

Consent & Acknowledgements