24Sculpt

1
Is this telehealth visit for yourself?* This field is required.
YESNO
2
Where are you presently located?* This field is required.We need to make sure we are currently licensed in your state.
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
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Maryland
Massachusetts
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Ohio
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South Dakota
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3
Name* This field is required.
First Name
Last Name
4
Email* This field is required.
example@example.com
Email Verified
The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification
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5
Address* This field is required.Please enter your street address, city, state and zip code. The address entered here will be the address used to ship your medication to.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
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Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
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Australia
Austria
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The Bahamas
Bahrain
Bangladesh
Barbados
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Belgium
Belize
Benin
Bermuda
Bhutan
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Botswana
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Brunei
Bulgaria
Burkina Faso
Burundi
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Central African Republic
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Chile
China
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Cook Islands
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Cote d'Ivoire
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Dominican Republic
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Egypt
El Salvador
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Eritrea
Estonia
Ethiopia
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Faroe Islands
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Finland
France
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The Gambia
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Other
Country
6
Phone Number* This field is required.
Please enter a valid phone number.
7
Date of Birth* This field is required.Please fill in the date that you were born.
Date
Month
Day
Year
8
Do you or anyone in your family have a history of medullary thyroid carcinoma?* This field is required.
YESNO
9
Do you have a history of pancreatitis?* This field is required.
YESNO
10
What is your weight and height?* This field is required.
11
Are you an existing 24sculpt.com patient?* This field is required.
YESNO
12
Thank you for continuing to use 24Sculpt for your medical weight loss needs. Although you are a returning patient, we have a few questions to ask to make sure that nothing has changed since your last visit.
13
Are you currently taking semaglutide/cyanocobalamin or tirzepatide/niacinamide?
semaglutide/cyanocobalamin
tirzepatide/niacinamide
14
Do you want to switch the type of medication you are taking today?
No
Yes, I want to switch to semaglutide/cyanocobalamin.
Yes, I want to switch to tirzepatide/niacinamide.
15
What is your current dose of semaglutide/cyanocobalamin?* This field is required.
0.25mg per week
0.5mg per week
1.5mg per week
2mg per week
Other
16
What is your current dose of tirzepatide/niacinamide?* This field is required.
2.5mg per week
5mg per week
7.5mg per week
10mg per week
12.5mg per week
15mg per week
Other
17
When was the last time you took semaglutide/B12?* This field is required.
Less than 1 month ago
More than 1 month ago
18
When was the last time you took tirzepatide/niacinamide?* This field is required.
Less than 1 month ago
More than 1 month ago
19
Would you like to increase the dose of your medication today?* This field is required.
YESNO
20
Would you like to increase the dose of your medication today?* This field is required.
YESNO
21
Select your goal of weight loss treatment* This field is required.
Improve quality of life
Treat and reverse the complications of obesity
Prevent the complications of obesity
22
How many pounds would you like to lose in the next 3 months?* This field is required.Enter a number
Enter number
23
Weight Reduction & Safety Disclosure* This field is required.All fields are required to be checked.
24
I have read the Weight Reduction & Safety Disclosure and Consent to Proceed* This field is required.
AGREE
25
How would you categorize your current weight?* This field is required.
Underweight (BMI below 18.5)
Healthy weight (BMI between 18.5 and 24.9)
BMI between 27 and 29.9
Obese (BMI between 30 and 39.9)
Morbidly obese (BMI above 40)
Unsure
26
What is your waist size/circumference in inches?* This field is required.Type a number in inches
Inches
27
Which of these conditions do you currently have or have had in the past?* This field is required.
None of the conditions below
Liver Disease or Kidney Disease
Diabetic Retinopathy
Depression or other mental health disorder
Gastroparesis
Pancreatitis
Gallbladder Disease
Hypoglycemia (low glucose)
Arrhythmias or Abnormal Heart Rate
Seizure Disorder (epilepsy)
Suicidal Behavior and Ideation
Thyroid Tumors or Cancer
Multiple Endocrine Neoplasia Syndrome
28
Which of these weight loss measures have you tried?* This field is required.
Weight loss exercises
Diet
Portion control and calorie count
Behavior therapy by a trained personnel
Weight loss supplements
Weight loss Apps
29
Are you currently on or have you previously used semaglutide, ozempic, or wegovy?* This field is required.
I am currently on semaglutide, ozempic, or wegovy.
I have used semaglutide, ozempic, or wegovy within the past month.
It has been more than 1 month since I have used semaglutide, ozempic, or wegovy.
I have never used semaglutide, ozempic, or wegovy.
30
Are you currently on or have you previously used tirzepatide, mounjaro, or zepbound?* This field is required.
I am currently on tirzepatide, mounjaro, or zepbound.
I have used tirzepatide, mounjaro, or zepbound within the past month.
It has been more than 1 month since I have used tirzepatide, mounjaro, or zepbound.
I have never used tirzepatide, mounjaro, or zepbound.
31
If you are currently on or have used semaglutide, ozempic, or wegovy within the past 1 month, what dose are/were you on? If you have been on any of these medications in the past month, this dose will be offered to you if you qualify for a prescription.* This field is required.
0.25mg per week
0.5mg per week
1mg per week
1.7mg per week
2mg per week
2.4mg per week
Other
32
If you are currently on or have used tirzepatide, mounjaro, or zepbound within the past 1 month, what dose are/were you on? If you have been on any of these medications in the past month, this dose will be offered to you if you qualify for a prescription.* This field is required.
2.5mg per week
5mg per week
7.5mg per week
10mg per week
12.5mg per week
15mg per week
Other
33
Have you been evaluated or treated for weight loss by a doctor?* This field is required.
YESNO
34
Briefly describe your previous encounter with the doctor, including previous treatments.* This field is required.Include previous treatments
Huge
Large
Normal
Small
Ok
Ok
35
Which of these weight loss interventions have you explored in the past?* This field is required.
Prescription medication for weight loss
Liposuction
Bariatric surgery
Acupuncture
Other surgical interventions
Other interventions
None of the above medical interventions
36
Please upload a full body (head to toe) image of yourself. (Optional)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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37
Is there any information you would like to share with your medical provider today? (Optional)
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Large
Normal
Small
Ok
Ok
38
Are you allergic to any drug?* This field is required.
YESNo drug allergies (NKDA)
39
What medications are you allergic to?* This field is required.
40
Select the underlying medical conditions you have currently or have had in the past.* This field is required.
None, I do NOT have any chronic medical or psychiatric conditions
Heart disease
Hypertension
Liver disease
Kidney disease
Diabetes
High cholesterol
Thyroid disorder
Psychiatric condition
HIV/AIDS
Other condition
41
Type of heart disease* This field is required.
Coronary Artery Disease (CAD) or heart attack
Heart Valve Disease
Arrhythmias or abnormal heartbeat
Heart Failure or CHF
Congenital Heart Disease
Cardiomyopathy (Heart Muscle Disease)
Pericardial Disease
Other heart diseases
42
How stable or controlled is your diabetes?* This field is required.
Well controlled (Glucose below 150 or HbA1c less than 8)
Somewhat controlled (Glucose below 200 or HbA1c less than 9)
Uncontrolled Diabetes (Glucose over 200 or HbA1c over 9)
43
Select applicable psychiatric conditions* This field is required.
Depression
Anxiety
Panic Disorder
Bipolar or mood disorder
Schizophrenia or psychosis
PTSD
Eating disorder
OCD
Other psychiatric conditions
44
What's your average blood pressure reading?* This field is required.
Normal (Less than 140/90)
Elevated (Less than 160/100)
Uncontrolled (Over 160/100)
45
Are you currently taking any medication?* This field is required.
YESNO
46
Enter medication names* This field is required.
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Normal
Small
Ok
Ok
47
What is your biological sex (gender at birth)?* This field is required.
FemaleMale
48
Are you currently breastfeeding (nursing)?* This field is required.
YESNO
49
When did your last menstrual cycle end (Pregnancy Screening)?* This field is required.
My period ended within the last 30 days
I AM PREGNANT
I am currently on my period
I haven't had a period in 30 days (Late period)
I am a transgender woman
I am postmenopausal and do not have menstrual cycles
I am a child and have NEVER had a menstrual cycle (Premenarchal)
50
Please select a reason for your late, missed, or irregular cycle. (Rule Out Pregnancy.)* This field is required.
I am on birth control or hormone therapy
Due to a medical condition that causes menstrual irregularity
After a surgical procedure such as hysterectomy or endometrial ablation
I may be pregnant
Other reasons
51
Please explain why your cycle is irregular or missed.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
52
Select applicable surgical history.* This field is required.
None, No surgical past
Appendectomy
Breast augmentation
C-section
Gallbladder surgery
Hysterectomy
Hernia repair
Mastectomy
Orthopedic surgery
Tonsillectomy
Other surgery
53
List any other past surgeries.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
54
Which of these social histories applies to you?* This field is required.
I drink coffee or caffeinated drinks regularly
Current smoker (Vape, cigarette or tobacco)
Former cigarette or tobacco use
Marijuana use
Opioid Addiction
Alcohol Addiction
Recreational or illicit drug use
None of the above
55
When was your last in-person visit to the doctor?-* This field is required.
In the last 3 months
In the last 3 to 6 months
In the last 6 to 12 months
Over a year ago
I have NEVER sees a doctor in-person
56
Given the limitations of telemedicine, we encourage an in-person follow up if your medical concerns do not resolve after a telemedicine visit.* This field is required.
I agree to follow-up for an in-person re-evaluation with a local doctor as neededI have an upcoming appointment with my doctor
57
When is your next doctor's appointment?
Date
Year
Month
Day
58
I understand that 24Sculpt will prescribe either a 1 month or 3 month supply of medication at a time. I will need to return in 3 weeks or 2.5 months for a follow up visit for re-evaluation and refills.* This field is required.
I understand.
59
24Sculpt does not accept insurance.* This field is required.
I understand.
60
Payment and Refund Policy* This field is required.All fields are required to be checked.
61
Refund Policy* This field is required.
62
Informed Consent and Authorization to Administer Treatment* This field is required.
63
Semaglutide/Tirzepatide Consent Form* This field is required.
64
Please sign below that you have read the Informed Consent and Semaglutide/Tirzepatide Consent Forms and that you have provided your medical history to the best of your knowledge and agree to ALL terms and conditions.* This field is required.
Clear
65
Were you referred by someone? If so, please type their full name (first and last) below.
66
If you are planning to purchase tirzepatide/niacinamide, please note that we currently do NOT offer higher doses of tirzepatide/niacinamide (any dose over 5mg per week) due to the costs of this medication.* This field is required.
I understand
67
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ORDER SUMMARY
TaxUSD
SubtotalUSD
Total costUSD
Semaglutide/cyanocobalamin (1 month supply) + telehealth appointmentYou will receive a 1 month supply of semaglutide/cyanocobalamin that will be delivered directly to your address. In addition, you will charged a 1 time fee for a telehealth visit. The total for the 1 month supply semaglutide/B12 + the 1 time telehealth visit is $320. Should you like to continue your prescription after 1 month, you will need to complete another telehealth visit and purchase of semaglutide at that time.
$320.00Edit
Back
3 month supply of tirzepatide/niacinamide + FREE telehealth appointmentFREE telehealth visit with a 3 month supply purchase! You may choose to purchase a 3 month supply of tirzepatide/niacinamine. You will be charged for the entire 3 month period and each month your tirzepatide/niacinamide will be directly delivered to your address. If you choose this option, your telehealth visit will be FREE at this time. The complete cost for a 3 month supply + telehealth visit is $1,110. If you choose to continue your prescription after the 3 month period, you will be required to complete a follow up telehealth visit and purchase your prescription again at that time.
$1,110.00Edit
Back
3 month supply of semaglutide/cyanocobalamin + FREE teleheallth appointmentFREE telehealth visit with a 3 month supply purchase! You may choose to purchase a 3 month supply of semaglutide/B12. You will be charged for the entire 3 month period and each month your semaglutide/B12 will be directly delivered to your address. If you choose this option, your telehealth visit will be FREE at this time. The complete cost for a 3 month supply + telehealth visit is $870. If you choose to continue your prescription after the 3 month period, you will be required to complete a follow up telehealth visit and purchase your prescription again at that time.
$870.00Edit
Back
Tirzepatide/niacinamide (1 month supply) + telehealth appointmentYou will receive a 1 month supply of tirzepatide/niacinamide that will be delivered directly to your address. In addition, you will charged a 1 time fee for a telehealth visit. The total for the 1 month supply tirzepatide/niacinamide + the 1 time telehealth visit is $400. Should you like to continue your prescription after 1 month, you will need to complete another telehealth visit and purchase tirzepatide at that time.
$400.00Edit
Back
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Invoice ID
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