Weight Loss Medication

Weight Loss Medication Qualification Form

We’ll ask a few questions about your health and lifestyle to determine if this breakthrough option is right for you. Since demand is high, let's get started right away to see if you qualify!

Name*
E-mail*
Phone Number*
Date Of Birth (21 or older only!)*

MonthDayYear
State/Province*
State/Province*

Street Address

Street Address Line 2

City

Zip Code

What’s your current weight and height?
Weight*
Height*

Have you tried diet and exercise to lose weight before?*

YesNo

Do you have any of these health conditions?*

Type 2 diabetesHigh blood pressureHigh cholesterolSleep apneaNone of the above

Are you currently taking any prescription medications?*

YesNo
If you choose yes please put list. *

Do you have any allergies?*

YesNo
If you choose yes please put list. *

Have you ever been diagnosed with any of the following? ( If answered yes to any of these, STOP, you do not qualify)*

Personal or family history of medullary thyroid cancer (MTC)Multiple Endocrine Neoplasia type 2 (MEN2)PancreatitisGastroparesis (delayed stomach emptying)Allergy or hypersensitivity to weight loss medications (such as GLP-1s)Pregnancy or currently breastfeedingNone of the above
⚠️ Important:*

If you checked any of the boxes above (except “None of the above”), you are not eligible for GLP-1 medications.

1. Purpose and Nature of Telehealth Services

You, the patient, understand that telehealth services involve the use of electronic communications to consult with, diagnose, and/or treat health conditions remotely. Telehealth may include videoconferencing, audio communication, and/or digital transmission of medical data.

2. Patient Acknowledgements and Responsibilities

By signing this consent, you affirm and agree to the following:

• Legal Capacity: You confirm that you are 18 years of age or older and have the legal capacity to provide informed consent for telehealth services. If you are under 18, a legally authorized parent or guardian must complete this form on your behalf.
• Voluntary Participation: You are voluntarily choosing to participate in telehealth services. You may refuse or discontinue services at any time without affecting your right to future care or treatment.
• Assumption of Risk: You acknowledge and accept all risks associated with telehealth, including but not limited to: o Interruptions, technical difficulties, and unauthorized access to communication. o Limitations in diagnosis due to the absence of physical examination. o Delays in treatment due to system or communication failure.
• Accuracy of Information: You agree to provide complete and accurate health information and understand that the provider relies on the accuracy of your statements.
• Technology Requirements: You are solely responsible for securing the technology and internet connection used for telehealth sessions. You understand that poor connectivity or technical failure on your part may compromise care and is not the responsibility of the provider.
• Environment for Care: You agree to ensure your environment is private, safe, and free from distractions during the session. The provider is not liable for confidentiality breaches caused by your chosen location.

Disclaimer:

If switching between Semaglutide and Tirzepatide, wait at least 2 weeks before starting the new medication and always begin at the lowest dose.
If you are unsure which dose to select, it’s okay to choose any dose — the final dose will be determined by your medical provider.
Do not purchase or use if you are allergic to Vitamin B, GLP-1/GIP medications, or peptides.
Patients are responsible for following these guidelines to help reduce the risk of side effects or complications.

Products

Semaglutide (with B6 or B12)

$299.00 QuantityDose Options

Tirzepatide (with B6 or B12)

$399.00 QuantityDose Options

Total

$0.00

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Weight Loss Medication Qualification Form

What’s your current weight and height?

Disclaimer: