24Sculpt.com membership

Where are you presently located?* This field is required.We need to make sure we are currently licensed in your state.

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

Which insurance plan do you have?

Aetna

Ambetter

Blue Cross Blue Shield

Cigna

First Health

Healthy Blue

Medicaid

Medicare

Tri-Care

United Healthcare

Verity

Other

Please note that we are not currenlty considered in-network with your insurance company.

Therefore, any out-of-network costs, such as copays, coinsurance and deductibles may apply to your visits and nutrition and activity monitoring. These costs are in addition to your monthly membership fee. If you wish to continue and fill out this form and are found to be eligible at the end of this form, you may book a FREE appointment with our provider who may be better able to determine the cost of these fees based on your insurance.

Date of Birth* This field is required.Please fill in the date that you were born.

Date

Name* This field is required.

First Name

Last Name

Email* This field is required.

example@example.com

Email Verified

The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification

••••

Address* This field is required.Please enter your street address, city, state and zip code. The address entered here will be the address used to ship your medication to.

Street Address

Street Address Line 2

City

State

Zip Code

Country

Phone Number* This field is required.

Please enter a valid phone number.

Do you or anyone in your family have a history of medullary thyroid carcinoma?* This field is required.

YESNO

Do you have a history of pancreatitis?* This field is required.

YESNO

Are you allergic to any drug?* This field is required.

YESNo drug allergies (NKDA)

What medications are you allergic to?* This field is required.

What is your weight and height?* This field is required.

Based on the calculation from your height and weight in the last question is your BMI equal to or greater than 25?

YESNO

Which of these conditions do you currently have or have had in the past?* This field is required.

None of the conditions below

Liver Disease or Kidney Disease

Gastroparesis

Pancreatitis

Gallbladder Disease

Hypoglycemia (low glucose)

Arrhythmias or Abnormal Heart Rate

Seizure Disorder (epilepsy)

Suicidal Behavior and Ideation

Thyroid Tumors or Cancer

Multiple Endocrine Neoplasia Syndrome

HIV/AIDS

Heart Failure or CHF

Coronary Artery Disease (CAD) or Heart Attack

Cardiomyopathy

Congenital Heart Disease

What is your biological sex (gender at birth)?* This field is required.

FemaleMale

Are you currently breastfeeding (nursing)?* This field is required.

YESNO

When did your last menstrual cycle end (Pregnancy Screening)?* This field is required.

My period ended within the last 30 days

I AM PREGNANT

I am currently on my period

I haven't had a period in 30 days (Late period)

I am a transgender woman

I am postmenopausal and do not have menstrual cycles

I am a child and have NEVER had a menstrual cycle (Premenarchal)

Please select a reason for your late, missed, or irregular cycle. (Rule Out Pregnancy.)* This field is required.

I am on birth control or hormone therapy

Due to a medical condition that causes menstrual irregularity

After a surgical procedure such as hysterectomy or endometrial ablation

I may be pregnant

Other reasons

24Sculpt.com membership