Submitting your medication request…

Medical Qualification

Medical Weight Loss

Please answer the following questions so we can qualify you for medical weight loss treatment.

Body

DOB

Screen

Conditions

History

Details

Review

Result

Body Metrics

What is your height and weight?

Feet *

Please select your height in feet.

Inches *

Please select inches.

Weight (in lbs) *

Please enter your current weight.

Goal Weight (in lbs) *

Please enter your goal weight.

Are you male or female? * Male Female

Please select your gender.

Date of Birth

What is your date of birth?

Month *

Please select a month.

Day *

Please select a day.

Year *

Please select a year.

Health Screening

Do any of these apply to you?

⚠️ For your safety, certain answers may disqualify you from a prescription.

Select all that apply * End-stage kidney disease (on or about to be on dialysis) End-stage liver disease (cirrhosis) Current suicidal thoughts and/or prior suicidal attempt Cancer (active diagnosis, active treatment, or in remission for less than 5 continuous years – does not apply to non-melanoma skin cancer cured via simple excision) Severe gastrointestinal condition (gastroparesis, blockage, inflammatory bowel disease) Current diagnosis of or treatment for alcohol, opioid, or substance use disorder/dependence None of the above

Please select at least one option.

Personal Information

Almost done! We need a few details to proceed.

First Name *

Please enter your first name.

Last Name *

Please enter your last name.

Phone Number *

Please enter your phone number.

Email Address *

Please enter a valid email address.

What state will your medication be shipped to? *

Please select a state.

🔒 Your information is never shared and is protected by HIPAA.

Your Medical Review

-- BMI

-- Current Weight

-- Goal Weight

-- Est. Timeline

Your preliminary screening score is --%. Final eligibility will be determined by a licensed provider after reviewing your complete medical history.

Review Your Information

Please review your details before submitting your medication request.

Name	--
Phone	--
Email	--
Height	--
Gender	--
Shipping State	--

Consent & Acknowledgments

I acknowledge that my health information will be handled in accordance with HIPAA regulations and TeyaRx's Privacy Policy. I understand that the compounded GLP-1 medications offered by TeyaRx are not FDA-approved, are not the same as brand-name products (e.g., Ozempic®, Wegovy®, Zepbound®), and carry risks including but not limited to nausea, vomiting, pancreatitis, and gallbladder disease. I have reviewed the full risk disclosures. I agree to the Terms of Service and understand that submitting this form does not guarantee eligibility or a prescription. A licensed provider will review my information before any treatment is prescribed.

Medical Weight Loss

Body Metrics

Date of Birth

Health Screening

Additional Health Conditions

Medical History

Personal Information

Your Medical Review

Review Your Information