Skinii Onboarding

1
How Much Weight Do You Want To Lose?* This field is required.
Less Than 20 lbs.
More Than 20 lbs.
2
What are your weight management goals?* This field is required.
Look Better
Feel Healthier
Both
Other
3
Great! Skinii Meds is here to help you on your journeyOur Treatment memberships are doctor-supported & all prescribed medications come from licensed pharmacies in the USA!
4
What compounded management medication do you have in mind?
Injectable
Oral
Not Sure
5
Plans Starting As Low as $149Includes everything in one great low price.
6
Contact DetailsLets collect the information needed for your provider.
First Name
Last Name
7
Email
example@example.com
8
Phone Number
Please enter a valid phone number.
9
Sex Assigned At Birth
Male
Female
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Preferred Gender Pronouns
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Terms and Conditions* This field is required.
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I consent to receive marketing and SMS communications on offers from Skinii Corp.*Message and data rates may apply.
YESNO
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General Health QuestionnaireInformation your provider needs to prescribe medication.
Please Select
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Your Weight
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Age
Birthdate
14
BMI Calculator* This field is required.Know your BMI and help us determine if you qualify for medical weight loss treatment.
15
Do you currently have a government insurance plan?Let us know if you hold a government funded primary or secondary plan. This doesn't include federal, state, or city employee plans.
YESNO
16
Which type of health insurance do you have?
Employer or commercial insurance
Discount plan
Federal, state or city employee
Uninsured
17
Have you seen your primary care provider in the past 12 months?
YESNO
18
Are you currently pregnant or trying to become pregnant?For your safety if you become pregnant, please stop taking all weight loss medications immediately and notify your Care Team.
No
Yes, I am currently pregnant
Yes, I am currently trying to get pregnant and am having sex without birth control
19
Are you currently breastfeeding?We ask to better tailor treatment options to you
YESNO
20
Do you currently have, or have you ever been diagnosed with, any of the following heart or heart-related conditions?Select all that apply
Atrial fibrillation or flutter
Tachycardia (episodes of rapid heart rate)
Heart Rate
Heart diseases, stroke, or peripheral vascular disease
Prolonged QT interval
Other heart rhythm issues or ECG abnormalities
Hypertension (high blood pressure)
Hyperlipidemia (high cholesterol)
Hypertriglyceridemia (high triglycerides)
No I have not been diagnosed with any of these heart conditions.
21
Do you currently have, or have you ever been diagnosed with, any of these hormones, kidney, or liver conditions?Select all that apply
Multiple Endocrine Neoplasia syndrome type 2 (MEN2)
Personal history of thyroid cancer
Chronic kidney disease
Diabetes requiring insulin
Prediabetes and Insulin resistance
Fatty liver disease (NAFLD or NASH)
Kidney stones
Liver cirrhosis or end stage liver disease
No I do not have any of these conditions.
22
Do you currently have or have you ever been diagnosed with type 2 diabetes?
Yes
No
No, but I have a parent or sibling with type 2 diabetes
23
Do you currently have or have you ever been diagnosed with diabetic retinopathy?
Yes
No
I don't know
24
Do you currently have, or have a history of, any of these gastrointestinal conditions or procedures?
Bariatric surgery
Pancreatitis
History of delayed gastric emptying or gastroparesis
Gallstones or other gallbladder disease
GERD/ Acid Reflus
No, I do not have a history of any of these conditions or procedures.
25
Do you currently have, or have you ever been diagnosed with, any of these additional following conditions?Select all that apply
Chronic candidiasis (fungal infections)
Eating disorder
Gout
Hirsutism (excess body hair in women)
History of suicide attempt or history of suicidal ideation
Lymphedema or chronic lower extremity swelling where other causes have been ruled out
Metabolic syndrome
Obstructive sleep apnea
Osteoarthritis
Tinea infections (skin folds)
No, I have not been diagnosed with any of these conditions
26
Do you have any allergies?
Yes
No
Unknown
27
List any allergies belowIf none skip this question
28
Do you have an allergy to GLP-1 agonist medications?Examples include Tirzepatide (Zapbound/Mounjauro), liraglutide (Saxenda/Victoza), Semaglutide (Wegovy/Ozempic, and dulaglutide (Trulicity).
YESNO
29
Do you currently take any of the following medications?Select all that apply
A GLP-1 agonist such as (but not limited to) semaglutide (Wegovy/Ozempic), liraglutide (Sacenda/Victoza), dulaglutide (Trulicity), tirzepatide (Zepbound/Mounjaro)
Sulfonylureas such as (but not limited to) glipizide (Glucotrol), glimepiride (amaryl)
Insulin
Warfarin (also called Jantoven or Coumadin) - a blood thinner that usually requires regular lab testing
Meglitinides such as repaglinide or nateglinide
Diuretics such as (but not limited to) furosemide (Lasix), bumetanide (Bumex) Hydrochlorothiazide/HCTZ
Selective Serotonin Reuptake inhibitor (SSRI) such as (but not limited to) citalopram (Celexa), fluoxetine (Prozac), escitalopram (Lexapro)
Monoamine Oxidase Inhibitor (MAOI) such as (but not limited to) phenelzine (Nordil), selegiline (Emsam)
None of the above
30
List any medications, vitamins, dietary supplements, and topical creams you are currently taking or using.Include prescription and over the counter medications, herbs, minerals, inhalers, injections, and medication implants or patches. Do note include any medications the Skinii is prescribing.
31
How would you describe yourself? Select all that apply.Knowing your race and.or ethnic background helps us work toward improving equally accessible, high-quality care for everyone on our platform. However, you are not required to provide this information, and it won't impact your treatment if you don't.
White
Black or African American
Hispanic or Latino
Native American or American Indian
Asian/ Pacific Islander
Other
I prefer not to answer
32
Is there anything else you want your health care provider to know about your health?Include any additional details about the conditions you've already reported.
YESNO
33

You've qualified for treatment
34
NEXT STEPS

Based on your answer GLP-1 may not be the right weight management treatment for you. GLP-1s are only appropriate for patients who meet specific screening criteria.

We recommend discussing your concern regarding potential weight loss treatment with your primary healthcare provider.

You can still benefit from the Skinii Tribe and work with our nutrition planner and the Skinii calorie counter and exercise plans available on the Skinii App.
35
What's Next?

Select your membership tier & check out. A Skinii affiliated provider will review your health information to make sure that GLP-1 is right for you.
36
Checkout Your Preferred Membership TierChoose your membership option from the list below. Prescription availability will be confirmed in your appointment. Payment authorization is finalized after physician consult and prescription.
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ORDER SUMMARY
Total costUSD
Oral Semagultide$149 First month sale price, $199 per month thereafter
$149.00Edit
Back
1
1
2
3
4
5
6
7
8
9
10
Quantity
Subtotal: $0.00
Semaglutide Injectable$197 First month price $299 per month thereafter
$199.00Edit
Back
Oral Tirzepatide$249 First month price $399 thereafter
$249.00Edit
Back
Tirzepatide Injection$349 First month price $449 thereafter
$349.00Edit
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Total cost $0.00
37
What state do you live in?This helps us connect you with a licensed provider in your state.
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38
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39
AppointmentSelect an appointment time to virtually meet with a provided and discuss your options.
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