One Life Meds Eligibility Form

1

Please enter your email* This field is required.

2

What is your legal first and last name?* This field is required.

First Name

Last Name

3

What is your height?* This field is required.Enter your height in feet/inches

Feet

Inches

4

What is your weight?* This field is required.Enter your weight in pounds

5

BMI Calculation

6

What is your phone number?* This field is required.

Please enter a valid phone number.

7

What is your date of birth?* This field is required.Must be 18+

Date

8

What state do you live in?

9

What is your sex at birth?* This field is required.

Male

Female

10

Are you currently on weight loss medication?* This field is required.

No

Yes

11

Do any of the following apply to you?* This field is required.Weight-related conditions

None

High Blood Pressure (Hypertension)

High Cholesterol (Hyperlipidemia)

Prior Bariatric Surgery

Pre-diabetes/Type 2 Diabetes

Prior Stroke/TIA or Coronary Artery Disease

Other

12

Tell us what is most important to you?* This field is required.Select all that apply

Losing weight

Improving physical health

Improving another health condition

Increasing confidence

Establishing healthier habits

Other

13

Which GLP-1 prescription are you interested in?* This field is required.

Compounded Tirzepatide

Compounded Semaglutide

14

Congrats, you are eligible!* This field is required.Please schedule your appointment on the next page!