Eligibility Form
Complete the form below to see if you qualify for treatment.
Let's get started
Tell us about yourself so we can find the right plan.
Height
Required
Required
Current Weight
lbs
Required
Goal Weight
lbs
Required
Gender
Please select your gender
Date of Birth
Required
Required
Required
You must be at least 18 years old.
Do any of these apply to you?
Do any of these also apply to you?
Medical History
Within the last 3 months, have you taken opiate pain medications and/or opiate-based street drugs?
Please select an option.
Have you had prior weight loss surgeries?
Please select an option.
Do you currently take any prescription medications?
Please select an option.
What is your blood pressure range?
Please select an option.
What is your average resting heart rate?
Please select an option.
Your preferences
Help us recommend the best treatment option for you.
Have you taken medication for weight loss within the past 4 weeks?
Please answer this question
Great! You have experience with GLP-1.
Tell us more about your GLP-1 medication history.
Please list the name, dose, and frequency of your GLP-1 medication.
Field is required
When was your last dose of medication?
Please select an option
What was your starting weight in pounds?
lbs
Field is required
Please upload a photo of your GLP-1 medication
If you are requesting a prescription for your current or higher dose, this is important. If you don't have a photo available, you can skip this.
Click to choose a file
Do you agree to only obtain weight loss medication through this program moving forward?
It's important not to "stack" weight loss medications
Please select an option
Great! You have experience with weight loss medication.
Tell us more about your medication history.
Please list the name, dose, and frequency of your weight loss medication.
Field is required
What was your starting weight in pounds?
lbs
Field is required
Do you agree to only obtain weight loss medication through this program moving forward?
It's important not to "stack" weight loss medications
Please select an option
A bit more about you
This helps our medical team personalize your plan.
Have you ever tried to lose weight in a weight management program (Jenny Craig, Weight Watchers, etc)?
Please answer this question
Do you have any further information which you would like our medical team to know?
Please answer this question
Please select the following options that you are interested in
Please select at least one option
Treatment preferences
Choose the options that best fit your goals.
Which of these is most important to you?
Please select your primary goal
GLP-1 is available as an injection or a dissolvable tablet. Which sounds best?
Please select a medication type
Your Weight Loss Snapshot
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BMI
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Current
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Goal
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Est. Timeline
Complete the form to see your eligibility.
Almost there
Enter your details to receive your personalized plan.
First Name
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Last Name
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Email
Please enter a valid email address
Phone Number
Please enter a valid phone number
Shipping State
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