Bliv Qualification Form (NEW)

1
What is your weight loss goal?Goals are important. We're excited to help you achieve yours!
Lose 1-20 lbs
Lose 21-50 lbs
Lose over 50 lbs
Maintain weight
Not sure
Other
2
Are you male or female?* This field is required.Our bodies are complex systems that are heavily influenced by our sex and hormones.
Male
Female
Prefer not to answer
3
How old are you?Age can impact weight loss due to changes in metabolism, activity levels, and hormone balance.
Under 18
18-29
30-39
40-49
50-64
65+
4
Which state do you live in?* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
5
Do any of these conditions apply to you?* This field is required.Any of these will disqualify you from using GLP-1 medications.
None (most common)
Currently pregnant
Breastfeeding
End-stage kidney disease
End-stage liver disease
Anorexia/bulimia
Suicidal thoughts
Active cancer
Organ transplants
Pancreatitis
Type 1 diabetes
Currently on insulin
Diabetic retinapthy
Thyroid cyst
6
medical
7
GLP-1 medications like Wegovy & Zepbound help with more than just weight loss.* This field is required.Select any below you struggle with.
High blood pressure (hypertension)
Type 2 diabetes
High LDL cholesterol, low HDL cholesterol, or high levels of triglycerides (dyslipidemia)
Coronary heart disease
Stroke
Gallbladder disease
Sleep apnea and breathing problems
PCOS (Polycystic Ovarian Syndrome)
Pre-Diabetes
None of these apply to me
8
How tall are you in feet?* This field is required.If you're 5' 3'' it would just be 5.
9
How tall are you in inches?* This field is required.If you're 5' 3'' it would just be 3. If you are exactly 5'0", leave it at zero and click next.
10
TOTALHEIGHT
11
What is your current weight?* This field is required.Bye bye current weight :)
12
Here's your current BMI
13
What is your goal weight?* This field is required.This is what we're excited about.
14
Awesome goal and guess what? These medications work!Thousands of people like Mary here, lose 15-25% of their body weight.
15
Alright...Lets get into the medication and program!The next few questions will help us know which medications and dosing to recommend.
16
Which GLP-1 medication are you currently taking?This will help us know where to start.
I'm not currently taking GLP-1 medication
Ozempic
Mounjaro
Wegovy
Zepbound
Compounded Semaglutide
Compounded Tirzepatide
17
Which GLP-1 medication do you prefer?The Bliv nurse practitioner will go over these options with you.
Ozempic
Mounjaro
Wegovy
Zepbound
Compounded Semaglutide
Compounded Tirzepatide
18
Insurance Navigation

Our Insurance Navigation Team supports all our members in accessing affordable medication.

What we do for you:

Contact your insurer on your behalf

Evaluate the most clinically appropriate GLP-1 options

Identify patient access programs to help reduce your costs
19
Does your insurance cover GLP-1 medications?Don't worry. We can run an instant search for you.
Yes
No
I have no idea
20
Which type of insurance do you have?* This field is required.
Employer / Commercial (Aetna, Blue Cross Blue Shield, Federal Employee Program, etc.)
Kaiser
Government (Medicare, Medicaid, Tricare, etc.)
Uninsured
21
Do you have a CareCredit account?* This field is required.
Yes
No
22
Thank you! How did you hear about us?* This field is required.
Facebook
Instagram
Google
Radio
Referral
Other
23
Please enter the full name of the person who referred you* This field is required.
24
disqualifier
25
What's your full name?* This field is required.
First Name
Last Name
26
What's a good phone number?* This field is required.
Please enter a valid phone number.
27
Do you have an email address?* This field is required.We don't send spam, just a good way to communicate.
example@example.com
28
Terms and Conditions* This field is required.If you qualify, one of our health coaches will message you go through your GLP-1 weight loss medication options.
29

Sorry, based on {disqualifier} you do not qualify for the Bliv program at this time.

We invite you to try again in the future. If you have any questions you can visit out website at joinbliv.com or email us at info@blivwell.com
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Insurance Navigation