Weight Loss Form

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4
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5
What is your email?* This field is required.
example@example.com
6
What is your approximate height?* This field is required.
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What is your approximate weight?* This field is required.
8
Please upload a picture of your government issued ID* This field is required.
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What gender were you assigned at birth?* This field is required.
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Female
10
Are you currently pregnant, breastfeeding, or trying to get pregnant?
YESNO
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Unfortunately, most weight loss medications are contraindiated in pregnant women, breastfeeding women, and women attempting to get pregnant
12
Do you live in the provinces of Quebec, Manitoba, Saskatchewan or Prince Edward Island?* This field is required.
YESNO
13
Unfortunately, based on your location we are unable to provide you with a presription.
14
Do you have any allergies to any medications?* This field is required.
YESNO
15
Which medications are you allergic to?
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Are you currently taking any prescription, over the counter or herbal medications?* This field is required.
YESNO
17
What prescription, over the counter, or herbal medications are you taking?
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Are you currently taking any medications for weight loss?* This field is required.
YESNO
19
What medications are you currently taking for weight loss?
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Do you have any of the following medical conditions?* This field is required.
Type 1 Diabetes
Type 2 Diabetes
Diabetic Retinopathy
Diabetic Ketoacidosis
Pancreatitis
Gallbladder Disease
Medullary Thyroid Carcinoma
Multiple Endocrine Neoplasia
Kidney disease/kidney insufficiency or transplant/Acute Kidney Injury
Bariatric Surgery or other GI Surgery
Liver Disease/Cirrhosis
Leber Hereditary
Optic Neuropathy
None of these apply to me
21
Unfortunately, due to your medical history we are unable to provide you with the prescription at this time. We feel it is best suited to get your prescription from your primary health care practitioner who is able to monitor you more closely.
22
Do you have any personal or family history of Multiple Endocrine Neoplasia, Type 2, (MEN 2) or Medullary Thyroid Carcinoma (MTC)? * This field is required.
YESNO
23
Unfortunately, due to your medical history we are unable to provide you with the prescription at this time. We feel it is best suited to get your prescription from your primary health care practitioner who is able to monitor you more closely.
24
Are you currently receiving Chemotherapy? * This field is required.
YESNO
25
Unfortunately, due to your medical history we are unable to provide you with the prescription at this time. We feel it is best suited to get your prescription from your primary health care practitioner who is able to monitor you more closely.
26
Are you currently taking any of the following medications?* This field is required.
Abiraterone acetate
Somatrogon-GHLA
Chloroquine
Flouroquinolones
Hydroxychloroquine
Insulin
Insulin secretagogues
None of these apply to me
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Unfortunately, due to your medical history we are unable to provide you with the prescription at this time. We feel it is best suited to get your prescription from your primary health care practitioner who is able to monitor you more closely.
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We require that you provide a recent blood pressure measurement within the last six months* This field is required.
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Good news! You are eligible for a prescription for weight loss medications. Click Next to continue to product selection
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Which dosage form would you prefer?* This field is required.
Injectable medications: Injected into the layer of tissue under your skin (called subcutaneous tissue). These medications are the most effective however may carry some risk of side effects such as nausea and constipation. Available as Mounjaro (active ingredient is Tirzepatide) or Ozempic/Wegovy (active ingredient is Semaglutide).
Sublingual Medications: Specially compounded Semaglutide (active ingredient in Ozempic) that goes under your tongue for fast absorption directly into your blood stream. These medications are given once daily, however there is no need for injections and come at a much cheaper monthly price!
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Which active ingredient would you prefer?* This field is required.
Ozempic (Semaglutide):Aproved for type 2 diabetes, but it's also widely used off-label for weight loss. It works by reducing appetite, slowing digestion, and regulating blood sugar, leading to significant weight loss in many patients. While Wegovy (a higher-dose version of semaglutide) is specifically approved for weight management, Ozempic has shown similar benefits. Common side effects include nausea, vomiting, and digestive issues.
(Mounjaro Tirzapetide): Mounjaro (tirzepatide) is a once-weekly injectable medication originally approved for type 2 diabetes, but it’s showing remarkable weight loss results. It works by activating both GLP-1 and GIP receptors, helping to reduce appetite, improve metabolism, and regulate blood sugar. In clinical trials, patients lost up to 20% of their body weight, making it potentially more effective than semaglutide.
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Would you prefer Mounjaro Vials or Mounjaro Pre-filled pens?* This field is required.
Mounjaro Vials. Staring at $399 per month.
Mounjaro Pre-filled pen. Starting at $490 per month.
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Which Dosage form would you prefer?* This field is required.Both options are made of a Health Canada approved form of Semaglutide. They are both daily doses that allow Semaglutide to be absorbed directly into your blood stream by being placed under the tongue without the need of injections
Semaglutide QuickStrips: Dissolvable strips that are placed your tongue for fast absorption into your blood stream
Semaglutide Sublingual Drops: Liquid drops that are placed under the tongue for fast absorption into your blood stream
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Please observe the following titration schedule for Sublingual Semaglutide Drops. Please note: the titration of schedule is dependent on your results and tolerability. The following titration schedule is a guideline and may not be approrpriate for you.

Month 1: Semaglutide .5 mg/mL; Take 1 mL once daily for 1 month ($100 per month)
Month 2: Semaglutide 1mg/mL; Take 1 mL once daily for 1 month ($120 per month)
Month 3: Semaglutide 2mg/mL; Take 1 mL once daily for 1 month ($140 per month)
Month 4 and ongoing: Semaglutide 3mg/mL; Take 1 mL once daily ($160 per month)
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Please observe the following titration schedule for Sublingual Semaglutide QuickStrips. Please note: the titration of schedule is dependent on your results and tolerability. The following titration schedule is a guideline and may not be approrpriate for you.

Month 1: Semaglutide 0.5mg ; Take 1 strip once daily for 1 month ($100 per month)
Month 2: Semaglutide 1mg ; Take 1 strip once daily for 1 month ($130 per month)
Month 3 and ongoing: Semaglutide 2mg: Take 1 mL once daily for 1 month ($150 per month)
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Please observe the following titration schedule for Ozempic/Wegovy. Please note: the titration of schedule is dependent on your results and tolerability. The following titration schedule is a guideline and may not be approrpriate for you.

Month 1: Ozempic 0.25 mg once weekly for 4 weeks ($299 per month)
Month 2: Ozempic 0.5 mg once weekly for 4 weeks ($299 per month)
Month 3: Ozempic 1 mg once weekly for 4 weeks ($299 per month)
Month 4: Wegovy 1.7 mg once wekly for 4 weeks ($480 per month)
Month 5 and ongoing: Wegovy 2.4 mg once weekly for 4 weeks ($529 per month)
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Please observe the following titration schedule for Mounjaro. Please note: the titration of schedule is dependent on your results and tolerability. The following titration schedule is a guideline and may not be approrpriate for you.

Month 1: Mounjaro 2.5 mg once weekly for 4 weeks ($399 per month)

Month 2: Mounjaro 5 mg once weekly for 4 weeks ($399 per month)

Month 3: Mounjaro 7.5 mg one weekly for 4 weeks ($440 per month)

Month 4: Mounjaro 10 mg once weekly for 4 weeks ($440 per month)

Month 5: Mounharo 12.5 mg once weekly for 4 weeks ($500 per month)

Month 6 and ongoing: Mounjaro 15 mg once weekly ($500 per month)
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Please observe the following titration schedule for Mounjaro. Please note: the titration of schedule is dependent on your results and tolerability. The following titration schedule is a guideline and may not be approrpriate for you.

Month 1: Mounjaro 2.5 mg once weekly for 4 weeks ($499 per month)

Month 2: Mounjaro 5 mg once weekly for 4 weeks ($499 per month)

Month 3: Mounjaro 7.5 mg one weekly for 4 weeks ($650 per month)

Month 4: Mounjaro 10 mg once weekly for 4 weeks ($650 per month)

Month 5: Mounharo 12.5 mg once weekly for 4 weeks ($899 per month)

Month 6 and ongoing: Mounjaro 15 mg once weekly ($899 per month)
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Your total all inclusive price
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How would you like our health care professionals to get in contact with you?* This field is required.
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Would you prefer pick-up or delivery of your medications?* This field is required.
Delivery
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Do you have any questions for our health care professionals?
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Thank you for using our platform!

You will receive an email with detailed instructions and further information about your chosen treatment plan. You will be notified when your medication is ready for pick up or when it has left the pharmacy for delivery with a tracking number. Please feel free to reach out to the pharmacy for any further clarifications or questions
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