GLP-1 Shots Qualification

GLP-1 Shots Qualification Form

Please complete all fields marked with a star. We will contact you if you qualify for this breakthrough treatment method.
Name*

First NameLast Name
Gender*

FemaleMale
Mobile Phone*
Please enter a valid mobile phone number.
Email Address*
example@example.com
Preferred Contact Method*

Text MessageEmailPhone Call
Clinic Location*

BakersfieldClovisScottsdale
Is $350 per month within your budget for GLP-1 shots weight loss?*

YesNo
GLP-1 Shots Qualification
Height (ft)*
Height (in)*
Height Inches
Weight (lbs)*
BMI
BMI: {bmi9} = Low

Based on your weight and height, you seem to be in the "Underweight" range, which disqualifies you from GLP-1 shots and our medical weight loss program. It's a good problem to have.
BMI: {bmi9} = Normal

Congratulations, you are in a normal and healthy weight range. Although GLP-1 shots is not "medically necessary", you may still be able to get started on one of our programs under "off-label" use.
BMI: {bmi9} = High

Based on your Body Mass Index (BMI), you are considered "overweight". GLP-1 shots may be medically indicated if you have one or more weight related illnesses, including diabetes, high blood pressure and / or high cholesterol. Please complete the next question below. Even if you have no medical problem, you may get started on one of our programs under "off label" use.
BMI: {bmi9} = Very High

Based on your Body Mass Index (BMI), your are in the "obesity" range, which qualifies you for our GLP-1 shots weight loss program.
Do you have any of the following (check all that apply or NONE)?*

NONEAsthmaDiabetesHeart AttackHeart DiseaseHigh CholesterolHypertension
Illness Score
Qualifies for GLP-1 Shots?

NOYES
Lead Source
Should be Empty:

GLP-1 Shots Qualification Form

GLP-1 Shots Qualification