Tirzepatide Eligibility Questionnaire

1
Do any of the following apply to you?* This field is required.Please select the options below that apply to you. If none apply, select "None of the Below".
None of the below
Currently pregnant
Breastfeeding
Hypothyroidism / Thyroid Dysfunction
Current or prior eating disorder (anorexia/bulimia)
Existing or pre-existing substance abuse
Cancer (active diagnosis or treatment)
History of organ transplant or anti-rejection medication
Prediabetes, type 1 diabetes, or an A1c above 5.
Current suicidal thoughts and/ or prior suicidal attempts
Severe gastrointestinal condition (gastroparesis, blockage, inflammatory bowel disease)
Current participation in or subscription to another medial weight loss program and/ or currently taking another medication for weight loss
2
Condition field
3

We're sorry, you are not eligible.

Certain pre-existing conditions or medical situations do not permit patients to take Tirzepatide (GLP-1).
4
Are you between the age or 18 - 70 years?* This field is required.Please select from below
YESNO
5

We're sorry, you are not eligible.

You must be between the ages of 18 to 70 years of age
to be prescribed Tirzepatide (GLP-1).
6
Date of birth* This field is required.Please provide your date of birth. You must be 18 years of age or older.
Month
Day
Year
7
What is your weight and height?* This field is required.To determine your BMI please enter your weight (lbs) and height (ft./inches). PLEASE NOTE: Your BMI must be 27 or higher to qualify for Tirzepatide (GLP-1).
8

We're sorry, you are not eligible.

Your BMI must be 27 or higher in order to qualify to
be prescribed for Tirzepatide (GLP-1).
9
Select Which State You Live* This field is required.Please Note: We do NOT currently provide service in the following states: Alabama, Mississippi
10

We're sorry, you are not eligible.

We do NOT currently provide service in the following states: Alabama, Mississippi
11
Are you currently prescribed Tirzepatide (GLP-1)?* This field is required.Let us know if you are already taking Tirzepatide (GLP-1)
YESNO
12
What is your current weekly Tirzepatide (GLP-1) dosage?* This field is required.Select your dosage below
Please Select
Please Select
1 mL (Starter Dose) 1 mg/mL (1 mg)
2 mL 5 mg/0.5 mL (20 mg)
3 mL 5 mg/0.5 mL (30 mg)
4 mL (2 x 2 mL) 5 mg/0.5 mL (40 mg)
5 mL 5 mg/0.5 mL (50 mg)
Please Select
13
Complete Your Contact Information Below* This field is required.Please complete this form with your legal contact information.
First Name
Last name
Email Address
Phone Number
14
Privacy Agreement* This field is required. .
Should be Empty: