Eligibility Form - Weight Loss

1
What's your core goal?* This field is required.We're here to support you in all these areas. For now, pick your top priority.
I want to lose weight
I want to control my diabetes
Improve my health
Other
2
How old are you?* This field is required.
Under 20
20-29
30-39
40-49
50-59
60-64
65+
3
Where do you live?* This field is required.Let's see if our licensed providers serve your state.
Please Select
Please Select
California
Other
(Disqualifier)
4
Are you currently taking any medication(s) for weight loss or diabetes?* This field is required.
For Weight Loss
For Diabetes
For Both
None
5
Is any of the following true for you?* This field is required.If you are in a life threatening situation, call National Emergency Hotline at *911 or visit your nearest emergency room. Response are not monitored in real-time by Openwell's Team.
I am expecting, nursing, or planning a pregnancy
I have a current or prior eating disorder (anorexia/bulimia)
I am experiencing thoughts of self-harm or have in the past
I have active cancer
I have a history of organ transplant on anti-rejection medication
I am currently or have previously experienced serious digestive (GI) problems that has needed medical attention
I have a current or previous history of pancreatitis
I am using insulin for diabetes (either Type 1 or 2)
I was currently or previously diagnosed with kidney or liver disease
I have had surgery to aid weight loss
None of the Above
6
Additional Risk Assessment* This field is required.To ensure the safety of all Openwell prospective patients, please carefully review and select the following conditions that apply.
I have a BMI (body mass index) of 27 or below
I have received an Hemoglobin A1c test result of 10% or more recently
I have had a TSH (thyroid test level) of 10 or above
I have been diagnosed with a thyroid cyst or nodule, thyroid cancer, medullary thyroid carcinoma, or multiple endocrine neoplasia syndrome type 2
I have a family member who’s been diagnosed with a thyroid cyst or nodule, thyroid cancer, medullary thyroid carcinoma, or multiple endocrine neoplasia syndrome type 2.
None of the Above
I’m not sure about one of the above
7
Join our waitlist!* This field is required.At Openwell, every customer matters. We’re not in your area yet, but we’re expanding! Join our waitlist by leaving your contact details, and we’ll let you know once our weight loss program is available in your state.
Please enter your email
State
8
Thanks for sharing!Openwell doesn’t appear to be a fit for you at this time based on the conditions you indicated in this form. If your circumstances change in the future, please get back in touch!
9
Congratulations, You Qualify!* This field is required.Get started with our GLP-1 weight loss program. Share your details below and we'll tailor a medication plan with practical weight loss guidance for you.
Please enter your Full Name
Please enter your Email
10
Not Sure If You Qualify? Let's Talk.* This field is required.Enter your email below, and we’ll reach out to discuss next steps. Together, we can determine eligibility and how we can assist you further.
Please enter your Full Name
Please enter your Email
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