YesMeds Order Form

Semaglutide Order form

Please complete this entire medical intake form and click "Submit" at the bottom. As long as you provide clear pictures, and concise information for our doctors; your order will be processed within 48 hours. From date of submission to our pharmacy, your medication is expected to arrive within 8-10 business days.
Input Current Weight/Height to calculate BMI*
Check if you have any of the following (you will NOT be prescribed Semaglutide if so)

BMI below 25Currently PregnantCurrently undergoing Cancer TreatmentHistory of Thyroid CancerDiagnosed with Multiple Endocrine Neoplasia syndrome type 2 (MEN2)History of end-stage kidney or liver failure/cirrhosis
Check the box if have any of the following obesity related conditions?

HTN (Also known as High Blood Pressure)HLD (Also known as Heart Disease)DM2 (Also known as Type 2 Diabetes)
This is Dr. Wright, a board certified physician licensed in your state. I am thrilled you want to lose weight and get in shape! THANK YOU for reaching out! I want you to be aware that GLP-1 medications are FDA approved to be used in people with a BMI > 30 or a BMI of 27-30 with an obesity related medical problem. Using these medicines for a BMI outside these parameters is considered an "off-label" use of the medicine and is not FDA approved. This does not necessarily make them any "riskier," but they are newer medicines which have been studied predominantly in people who have the BMIs as noted above. This means that the benefit of using these medications to lose weight may not outweigh the risks, which include GI side effects and pancreatitis. I do prescribe these medications off label to patients because I believe that there are worse ways to lose weight than these medications, which are pretty safe and well tolerated by most people. Do you agree to assume all risks from using these medications "off-label?"*

YESNO
Please provide a brief overview of your past medical history, current medications (including dosage), and any known allergies, if none - leave blank
Are you CURRENTLY taking Semaglutide or Tirzepatide from another provider?*

YesNo
If so, what is the current medication and dosage you are taking?
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date Of Birth*

MonthDayYear
Date
Shipping Address*
Please give the doctor a short summary of your current weight loss journey and goals. If you have any notes for the Doctor, please put them in the box below.*
Ex.) After struggling with stubborn belly fat for a while, I would like to try the medical weight loss path
State of Residence (State that is listed on your driver's license) *
Upload a photo of your government-issued photo ID or Driver's license.*

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Upload a full-body photo (see photo below for example)*

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Async/Sync (blank if Async)

My Products*

Semaglutide Treatment

$399.00 Quantity

Payment Methods

Credit Card

Cash App Pay

ACH Bank Transfer

Should be Empty:

Semaglutide Order form

Payment Methods