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1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.This is where we will text your link to join and schedule
Please enter a valid phone number.
4
Do you have a state-issued ID for the state you are in?* This field is required.
YESNO
5
Which state do you live in?* This field is required.
Please Select
Please Select
Arizona
Colorado
Connecticut
Delaware
Florida
Georgia
Idaho
Kansas
Kentucky
Maine
Maryland
Massachusetts
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oregon
Pennsylvania
Rhode Island
South Carolina
Texas
Utah
Vermont
Virginia
Washington
Washington D.C. (not a state, but included in list)
West Virginia
Wyoming
6
Are you currently prescribed Tirzepatide?* This field is required.
YESNO
7
What is your current dosage?
Please Select
Please Select
2.5mg/week
5mg/week
7.5mg/week
10mg/week
12.5mg/week
15mg/week
8
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Terms and Conditions* This field is required.By submitting your information, you authorize Tara Healthcare LLC (RecoveryDelivered.com) to send you text messages related to your care, promotions, and important service updates. Message and data rates may apply. Consent is not a condition of purchase or treatment.
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