EWLC - Eligibility Form

1

Do you live in the state of Texas?

YESNO

2

What are your health goals?* This field is required.

Type 2 Diabetes (blood glucose control and management)

Weight Loss

Boost Cellular Energy & Metabolism

Diabetes / Weight Loss / and Boost Energy

All of the choices above

3

How old are you?* This field is required.

4

Calculate your BMI below:* This field is required.

5

What is your current Body Mass Index (BMI)?* This field is required.Select the BMI range below from calculating it in the previous question.

BMI Range

6

Do you have any of the following conditions?* This field is required.

Type 2 Diabetes

High Blood Pressure

Pre-Diabetes

High Cholesterol

PCOS (Polycystic Ovarian Syndrome)

Sleep Apnea

None of the above

7

Have you ever been diagnosed with any of the following?* This field is required.

Type 1 Diabetes

Medullary Thyroid Cancer

MEN2 (Multiple Endocrine Neoplasia Type 2)

Active Cancer or History of Cancer (In Family)

Pancreatitis

Kidney or Liver Disease

None of the above

8

Are you pregnant, breastfeeding, or planning pregnancy?* This field is required.

YESNO

9

Have you been on GLP-1 medication before?* This field is required.

YESNO

10

Are you familiar with NAD+ therapy?* This field is required.

Yes, I’ve used it.

Yes, but not tried it.

No, but I’m interested.

No, not interested.

11

Please enter your name below* This field is required.

First Name

Last Name

12

Please enter your email* This field is required.

example@example.com

13

Please enter your phone number* This field is required.

Please enter a valid phone number.

14

What is your preferred method of communication?* This field is required.

Email

SMS/Text Message

Phone Call

No preference

15

Please review and agree to our consent terms.* This field is required.

16

✅ You may be eligible for GLP-1 for Diabetes and/or Weight Loss

Your Type 2 Diabetes and other criteria suggest you may benefit from GLP-1 medication designed for glycemic support.

17

✅ You may be eligible for our Hybrid Program

You meet the criteria for both GLP-1 and NAD+ therapies. Our Hybrid Program combines weight loss, metabolic health, and cellular rejuvenation.

18

✅ You may be eligible for NAD+ Therapy

Your interest and profile make you a good candidate for NAD+ injection therapy to support energy, metabolism, and cognition.

19

❌ Not Eligible

At this time, you may not be eligible for our therapy programs based on your responses. A clinician will still review and follow up with potential alternatives.

-------

*Note: You may have also gotten this message if you answer "No" in regards to your residence in the state of Texas. Empower Weight Loss Clinic (EWLC) is a virtual clinic that operates under Texas medical licensure. This means that we are only legally permitted to provide telemedicine services, including prescribing medications, to individuals who are physically located in Texas at the time of their visit.

Even though we are an online clinic, state-specific medical regulations apply to all care provided. Confirming your location ensures we remain in compliance with telehealth laws and licensing requirements, which are designed to protect both patients and providers.

If you have additional questions about this, our team is happy to help clarify at info@myewlc.com or 888-322-1050