GRT Performance
Look Better. Feel Better. Live Better.
Basic Information
What’s your full name?
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First Name
Last Name
What’s the best phone number to reach you?
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Please enter a valid phone number.
What’s your email address?
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example@example.com
What’s your age?
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Health Screening (Yes/No)
Are you currently pregnant, breastfeeding, or planning to become pregnant?
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Yes
No
Do you have a personal or family history of medullary thyroid cancer?
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Yes
No
Do you have a history of Multiple Endocrine Neoplasia Syndrome (MEN2)?
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Yes
No
Do you have a history of pancreatitis?
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Yes
No
Do you have severe gastrointestinal disease (like gastroparesis)?
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Yes
No
Do you have type 1 diabetes?
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Yes
No
Are you currently taking any other GLP-1 medications (like Ozempic, Wegovy, Trulicity)?
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Yes
No
Current Health & Goals
What is your current weight and height?
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Do you have type 2 diabetes or pre-diabetes?
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Are you currently on any prescription medications? (If yes, list them)
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What is your main goal with Semaglutide? (Ex: weight loss, better blood sugar, both)
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Do you consent to be evaluated by our licensed provider for Semaglutide treatment?
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Yes
No
Approved OR Not Approved
Submit
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