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1
Why are you reaching out today?
*
This field is required.
I want to continue my existing GLP‑1 prescription (purchase now)
I want to start Semaglutide (Ozempic) or Tirzepatide (Zepbound)
I need help establishing my maintenance dose and/or need to purchase GLP-1 medication
My insurance won't cover my GLP-1 (Zepbound, Mounjaro, Ozempic, Wegovy)
I’d like to schedule a consult to discuss medical weight loss.
I want DESIGNER GLP (Semaglutide / Tirzepatide blend)
Something else like get a get a prescription for metformin, wellbutrin, or got a UTI, need a refill
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2
Have you used Semaglutide(Ozempic) or Tirzepatide(Zepbound) before?
YES
NO
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3
Have you tried weight loss medication before?
Yes
No
Not sure
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4
What is your current weight?
Enter in pounds
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5
What is your goal weight?
Enter in pounds
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6
Which GLP-1 medication(Tirzepatide/Semaglutide) are you currently taking?
Semaglutide (Ozempic / Wegovy)
Tirzepatide (Zepbound / Mounjaro)
Not Sure
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7
What dose are you currently taking for Semaglutide ?
0.25 mg
0.5 mg
1 mg
2 mg
2.5 mg
Not sure / Need help
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8
What dose are you currently taking for Tirzepatide ?
2.5 mg
5 mg
7.5 mg
10 mg
12.5 mg
15 mg
Not sure / Need help
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9
Do you have any of the following health conditions?
PCOS
Type 2 Diabetes
Hypothyroidism
High Blood Pressure
History of Medullary Thyroid Cancer
None of the above
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10
Which GLP-1 medication are you interested in taking?
Semaglutide(Ozempic / Wegovy)
Tirzepatide( Zepbound / Mounjaro)
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11
How do you want to proceed on getting started ?
I just want to purchase medication
I’d like to schedule a consult first
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12
Are you open to using a compound version of this medication( same ingredient, lower cost)?
Yes
Not Sure
No
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13
What do you need help with ?
Education on options
Price comparison
Help choosing a medication
Want to book a free consult
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14
Are you currently at your goal weight?
Yes
No
Not sure did not keep track
Almost there only a few pounds more..
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15
How long have you been at your goal weight?
1 month
Greater than 3 month
Not yet almost there!!
Not sure if I should stop or continue losing more weight....
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16
Are you struggling to maintain your goal weight?
Yes
No
Not sure
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17
Which medication did your doctor prescribe?
Ozempic
Wegovy
Zepbound
Mounjaro
Don't remember / Not sure
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18
Why it did not get filled?
Insurance denied it
Too expensive
Pharmacy said its unavailable
Need help with prior authorization
Doctor office never responded back
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19
Are you open to using a compounded version of this medication (same ingredient, lower cost)?
Yes
Not sure
No
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20
When do you want to get restarted?
ASAP
This month
Still exploring options.. I will think about it..
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21
Whats your biggest goal for weight loss?
Lose weight. Get healthy and feel great!!
I have a special event planned and want to lose 10-15 pounds fast in 1-2 month...and want to keep it off for good..
I experience chronic inflammation and want to try GLP-1s to reduce my inflammation
I want to take GLP-1s for reducing risk of Alzheimer's
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22
Would you like us to ?
Send me the current pricing, along with any available discounts or special offers
Get help choosing the medication and learning more on how it works
Schedule a free consultation with a provider to discuss my options and learn more
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23
Options on your insurance situation what we can do !
Yes, I would like to get started on Tirzepatide or Semaglutide
I would like to get help getting prior authorization assistance with my insurance
Not sure but I would like to get more information or speak with someone to know more what we can do
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24
Options with Dr. Lee weight loss management program :
Yes, I am ready to get started with weight loss medication(Tirzepatide / Semaglutide and I would like to get a appointment with a provider for assistance
I have some questions on medical weight loss and I like to get a free consult with a provider to learn more
Not ready yet(Its okay!! please submit this intake and register to be on our contact list)
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25
Name
*
This field is required.
First Name
Last Name
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26
Email
*
This field is required.
example@example.com
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27
Phone Number
*
This field is required.
Please enter a valid phone number.
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28
Shipping Address
Where to send your GLP-1 medication
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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29
Jotform_GHL_TAG
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30
Jotform_GHL_MEDICATION
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31
Jotform_GHL_DOSE
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32
Direct Order Tirzepatide-Semaglutide
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33
jotform_intake
YES
NO
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34
Date
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Month
Day
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Minutes
AM
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