Welcome

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Terms and Conditions* This field is required.
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Are you 18+ years old?* This field is required.
YESNO
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What is your name?* This field is required.
Name
Last name
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How do you prefer we contact you?* This field is required.
Email
Phone number
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Your Email* This field is required.
example@example.com
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Your phone
Country code
phone number
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What are your goals with WLL Program?* This field is required.
Lose weight
Improve my general physical health
Improve another health condition
Increase confidence about my appearance
Increase energy for activities I enjoy
I have another goal not listed above
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Are you in any of the following states?* This field is required.ALABAMA ARKANSAS CALIFORNIA HAWAII KANSAS MICHIGAN MINNESOTA MISSISSIPPI
YESNO
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Date of birth* This field is required.
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
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American Samoa
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Isle of Man
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Western Sahara
Yemen
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Zimbabwe
Other
Country
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Sex* This field is required.
Male
Female
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Female Let’s start with where you are now* This field is required.
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Male Let’s start with where you are now* This field is required.
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Unfortunately you DO NOT qualify for our GLP-1 program. However, you are a candidate for our fat burners. Would you like to get started with our WLL Fat burner pills?* This field is required.
YESNO
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Do you have any of these condition?* This field is required.Atrial fibrillation or flutter Tachycardia, episodes of rapid heart rate Heart failure Heart disease, stroke, or peripheral vascular disease Prolonged QT interval Other heart rhythm problems or abnormal ECG Hypertension, high blood pressure Hyperlipidemia, high cholesterol Hypertriglyceridemia, high triglycerides No, I have not been diagnosed with any of these heart conditions
YESNO
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Have you seen your primary care provider in the last 12 months? We want to ensure that there is a provider overseeing your general care options.
YESNO
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Thanks you for your interest in our program Are you interested in learning more about our WLL community to learn more about our other Weight-loss resources?* This field is required.
YESNO
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Thanks you for your interest in our program.
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WLL does not accept public or private insurance, but you can easily cover your order using credit card or PayPal.* This field is required.
YESNO
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Have you seen your primary care provider in the last 12 months? We want to ensure that there is a provider overseeing your general care options.* This field is required.
YESNO
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We're excited to get you started at WLL! Make sure to also see a primary care provider
WLL Program is here to help you meet your goal to lose weight, but we're not a replacement for a primary care provider. Overweight and obesity are linked to other conditions for which you should get screening and treatment even if you start GLP-1 medication. In rare cases, those conditions can increase your risk of side effects on a GLP-1.In addition to weight management treatment with WLL, it's important to establish a relationship with a primary care provider that has a complete picture of your overall health.
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1.Do you have any of these condition?* This field is required.
Atrial fibrillation or flutter
Tachycardia, episodes of rapid heart rate
Heart failure
Heart disease, stroke, or peripheral vascular disease
Prolonged QT interval
Other heart rhythm problems or abnormal ECG
Hypertension, high blood pressure
Hyperlipidemia, high cholesterol
Hypertriglyceridemia, high triglycerides
No, I have not been diagnosed with any of these heart conditions
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Is it Medically Controlled?* This field is required.
YESNO
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Please enter medication and dosage amount
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Ok
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Do you have, or have you been diagnosed with any of the following hormonal, chemotherapy, or intestinal conditions? Select all that apply.* This field is required.
Multiple endocrine neoplasia syndrome, type 2
Personal history of thyroid cancer
Family history of thyroid cancer
Chronic kidney disease
Diabetes requiring insulin
Prediabetes or insulin resistance–
Fatty liver disease (NAFLD or NASH)
Kidney stones
Liver cirrhosis or end-stage liver disease
Hypothyroidism, low thyroid function
Hyperthyroidism, high thyroid function
Graves’ disease
Thyroid problems
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
No, I have not been diagnosed with any of these conditions
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Do you have, or have you been diagnosed with Type 2 diabetes?* This field is required.
YES
NO, but i have a parent or grand parent with Type 2 diabetes
No
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What was your hemoglobin A1C range in the past 12 months?* This field is required.
NORMAL LESS THAN 5.7
PREDIABETES 5.7 TO 6.4
DIABETES 6.5 TO 7.9
UNCONTROLLED DIABETES 8.0 OR GREATER
I DON’T KNOW
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Are you insulin dependent?* This field is required.
YESNO
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Do you have, or have you been diagnosed with diabetic retinopathy?* This field is required.
Yes
No
I don’t Know
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As you start the WLL Program, check in with your primary care provider about screening for diabetic retinopathy

Patients with overweight and obesity are at risk for having diabetes and its complications. Changes in the eye related to diabetes, specifically "diabetic retinopathy," can worsen in patients using a GLP-1.

We recommend that all Wll program patients consult with their primary care provider about screening for diabetes and its complications.
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Do you have or have a history of any of the following intestinal conditions or procedures? Select all that apply.* This field is required.
Bariatric surgery
Pancreatitis
History of delayed gastric emptying or gastroparesis
Gallstones or other gallbladder disease
GERD or acid reflux
No, I do not have a history of any of these conditions or procedures
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Do you have or have you been diagnosed with any of the following additional conditions? Select all that apply* This field is required.
Chronic fungal infections or candidiasis
Eating disorder
Gout
History of suicide attempt or suicidal ideation
Lymphedema or chronic lower extremity swelling where other causes have been ruled out
Metabolic syndrome
Obstructive sleep apnea
Osteoarthritis
Tinea infections
No, I have not been diagnosed with any of these conditions
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Search for and select all allergies you have. Include allergies to prescription or over-the-counter medications, herbs, vitamins, supplements, foods, dyes, or anything else. Our clinicians use this information to determine a safe and effective treatment.* This field is required.
YesI have no allergies
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Include allergies to prescription or over-the-counter medications, herbs, vitamins, supplements, foods, dyes, or anything else. Our clinicians use this information to determine a safe and effective treatment.
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Do you have an allergy to GLP-1 agonist medications? Examples include Tirzepatide, Subcutaneous Mounjaro, Liraglutide, Saxenda, Victoza, Semaglutide, Wegovy, Ozempic, and Dulaglutide (Trulicity)* This field is required.
YESNO
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Are you currently taking any of the following medications? Select all that apply.* This field is required.
Liraglutide, Dulaglutide
Sulfonylureas such as, but not limited to, Glipizide, Glimepiride, or Amaryl
Insulin
Warfarin, also known as Coumadin, a blood thinner that usually requires lab monitoring
Meglitinides such as, but not limited to, Repaglinide or Nateglinide
Diuretics such as, but not limited to, Furosemide, Lasix, Bumetanide, Bumex, or Hydrochlorothiazide (HCTZ)
Selective Serotonin Reuptake Inhibitors (SSRIs) such as, but not limited to, Citalopram (Celexa), Fluoxetine (Prozac), or Escitalopram (Lexapro)
Monoamine Oxidase Inhibitors (MAOIs) such as, but not limited to, Phenelzine (Nardil) or Selegiline (Emsam)
Exenatide
NONE OF THE ABOVE
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Have you ever taken Semaglutide, Tirzepetide, Retatrutide* This field is required.
YESNO
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Has it been in the last 6 months?* This field is required.
YESNO
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Are you looking for a new provider?* This field is required.
YESNO
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Search for and select any medications, vitamins, dietary supplements, and topical creams you are currently taking or using. Include prescriptions and over-the-counter medications, herbs, minerals, inhalers, injections, and implanted medications or patches. Do not include medications that WLL is prescribing.
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How would you describe yourself? Select all that apply. Knowing your race and ethnicity will help us work towards improving equitable access to quality healthcare for everyone on our platform. However, you do not need to provide this information, and it will not affect your treatment if you choose not to. Options:* This field is required.
White
Hispanic or Latino
Black or African American
Native American or American Indian
Asian and Pacific Islander
Other
Prefer not to answer
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Is there anything else you want your healthcare provider to know about your health? Please include any additional details about the conditions you have already reported.
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At this moment on of our specialist will review your file and will be in contact with you in the next 48 hours
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I will redirect you to https://myweightlosslab.com/product-category/fat-burner/
Go to cartNo
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I will redirect you to glp-1program* This field is required.
YESNO
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We currently do not have coverage in your state.
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