Let's get started
Simply fill out the short form below, and we'll connect you with one of our US-licensed medical providers.
What are you looking to accomplish by becoming an Instant Rejuvenate patient?
*
Lose weight
Improve general physical health
Increase confidence about my appearance
Increase energy for enjoyable activities
I have another goal not listed above
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Name
*
First Name
Last Name
Date of Birth
*
Please select a month
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Month
Please select a day
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Day
Please select a year
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Year
Phone Number
*
Email
*
example@example.com
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This will be the address the pharmacy will ship medication to.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Weight (pounds)
*
Height (feet)
*
Height (inches)
*
Do any of the following apply to you?
*
Currently pregnant, or planning to become pregnant in the next year
Currently breastfeeding
Currently being treated for cancer
Active eating disorder
Active gallbladder disease
Active substance abuse or dependency
Type 1 diabetes
Bariatric surgery (within the past 18 months)
Pancreatitis within the past 6 months, or a history of pancreatitis caused by taking a GLP-1
History of medullary thyroid cancer or MEN syndrome
None
Are you currently taking any medications?
*
Yes
No
If yes, please list it here
Please list any medication allergies you have here
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Have you previously used a weight loss medication?
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Yes
No
Did you experience weight issues as a child?
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Yes
No
Have you ever been diagnosed with polycystic ovary syndrome?
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Yes
No
Have you ever been diagnosed with diabetes?
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Yes
No
Have you ever been diagnosed with hypertension?
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Yes
No
Have you ever been diagnosed with childhood obesity?
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Yes
No
Is there a family history of obesity?
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Yes
No
Is there a family history of heart disease?
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Yes
No
Is there a family history of diabetes?
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Yes
No
Is there a family history of polycystic ovary syndrome (for females only)?
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Yes
No
Have you ever had a gastric bypass?
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Yes
No
Have you ever had a gastric band?
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Yes
No
Is there a family history of thyroid cancer?
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Yes
No
Is there a family history of multiple neoplasia 1 or 2 (cysts on endocrine glands)?
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Yes
No
Is there a family history of pancreatitis?
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Yes
No
Are you currently pregnant or plan on being pregnant within the next year?
*
Yes
No
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Payment Information
To reserve your selected appointment and initiate a membership to Instant Rejuvenate's telehealth services. This fee covers the costs of onboarding with one of our US-licensed medical provider.
Signature
*
Enroll
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