Clone of prescription only 24Sculpt

1
Is this prescription for yourself?* This field is required.
YESNO
2
Name* This field is required.
First Name
Last Name
3
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
••••
Didn't receive verification code?or
Receiving the email may take a few minutes, thank you for your patience!
4
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
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
State
Zip Code
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
5
Phone Number* This field is required.
Please enter a valid phone number.
6
Are you currently located in one of the following states: Arizona, Florida, Hawaii, Louisiana, Texas?* This field is required.
YESNO
7
Date of Birth* This field is required.Please fill in the date that you were born.
Date
Month
Day
Year
8
Do you or anyone in your family have a history of medullary thyroid carcinoma?* This field is required.
YESNO
9
Do you have a history of pancreatitis?* This field is required.
YESNO
10
Are you currently (within the past month) taking a GLP-1?
Yes. I take compounded semaglutide.
Yes. I take compounded tirzepatide.
I am currently on semaglutide, ozempic, or wegovy.
I am currently on tirzepatide, mounjaro, or zepbound.
No.
11
If you are currently on or have used semaglutide, ozempic, or wegovy within the past 1 month, what dose are/were you on? (Please choose the dose option closest to what you take.)* This field is required.
0.25mg per week
0.5mg per week
1mg per week
1.5mg per week
2mg per week
2.5mg per week
Other
12
If you are currently on or have used tirzepatide, mounjaro, or zepbound within the past 1 month, what dose are/were you on? (Please choose the dose option closest to what you take.)* This field is required.
2.5mg per week
5mg per week
7.5mg per week
10mg per week
12.5mg per week
15mg per week
Other
13
Would you like to increase the dose of your medication today?* This field is required.
YESNO
14
Do you want to switch the type of medication you are taking today?
No
Yes, I want to switch to semaglutide/cyanocobalamin.
Yes, I want to switch to tirzepatide/niacinamide.
15
What is your waist size/circumference in inches?* This field is required.Type a number in inches
Inches
16
What is your weight and height?* This field is required.
17
How would you categorize your current weight?* This field is required.
Underweight (BMI below 18.5)
Healthy weight (BMI between 18.5 and 24.9)
Overweight (BMI between 25 and 29.9)
Obese (BMI between 30 and 39.9)
Morbidly obese (BMI above 40)
Unsure
18
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
Diabetic Retinopathy
Depression or other mental health disorder
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
19
Are you allergic to any drug?* This field is required.
YESNo drug allergies (NKDA)
20
What medications are you allergic to?* This field is required.
21
Select the underlying medical conditions you have currently or have had in the past.* This field is required.
None, I do NOT have any chronic medical or psychiatric conditions
Heart disease
Hypertension
Liver disease
Kidney disease
Diabetes
High cholesterol
Thyroid disorder
Psychiatric condition
HIV/AIDS
Other condition
22
How stable or controlled is your diabetes?* This field is required.
Well controlled (Glucose below 150 or HbA1c less than 8)
Somewhat controlled (Glucose below 200 or HbA1c less than 9)
Uncontrolled Diabetes (Glucose over 200 or HbA1c over 9)
23
Select applicable psychiatric conditions* This field is required.
Depression
Anxiety
Panic Disorder
Bipolar or mood disorder
Schizophrenia or psychosis
PTSD
Eating disorder
OCD
Other psychiatric conditions
24
What's your average blood pressure reading?* This field is required.
Normal (Less than 140/90)
Elevated (Less than 160/100)
Uncontrolled (Over 160/100)
25
Are you currently taking any medication?* This field is required.
YESNO
26
Enter medication names* This field is required.
Huge
Large
Normal
Small
Ok
Ok
27
What is your biological sex (gender at birth)?* This field is required.
FemaleMale
28
Are you currently breastfeeding (nursing)?* This field is required.
YESNO
29
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)
30
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
31
Please explain why your cycle is irregular or missed.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
32
Select applicable surgical history.* This field is required.
None, No surgical past
Appendectomy
Breast augmentation
C-section
Gallbladder surgery
Hysterectomy
Hernia repair
Mastectomy
Orthopedic surgery
Tonsillectomy
Other surgery
33
List any other past surgeries.
Huge
Large
Normal
Small
Ok
Ok
34
Select your goal of weight loss treatment* This field is required.
Improve quality of life
Treat and reverse the complications of obesity
Prevent the complications of obesity
35
Which of these weight loss measures have you tried?* This field is required.
Weight loss exercises
Diet
Portion control and calorie count
Behavior therapy by a trained personnel
Weight loss supplements
Weight loss Apps
36
Which of these weight loss interventions have you explored in the past?* This field is required.
Prescription medication for weight loss
Liposuction
Bariatric surgery
Acupuncture
Other surgical interventions
Other interventions
None of the above medical interventions
37
Please upload a full body (head to toe) image of yourself. (Optional)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
38
Is there any information you would like to share with your medical provider today? (Optional)
Huge
Large
Normal
Small
Ok
Ok
39
Weight Reduction & Safety Disclosure* This field is required.All fields are required to be checked.
40
I have read the Weight Reduction & Safety Disclosure and Consent to Proceed* This field is required.
AGREE
41
24Sculpt does not accept insurance for visits.* This field is required.
I understand.
42
Telehealth Refund Policy* This field is required.All fields are required to be checked.
43
I understand that 24Sculpt will prescribe a 1 month supply of medication if I qualify. I will need to return in 3 weeks for a follow up telehealth visit for refills.* This field is required.
I understand.
44
Informed Consent and Authorization to Administer Treatment* This field is required.
45
GLP-1 Consent Form* This field is required.
46
Please sign below that you have read the Informed Consent and GLP-1 Consent Forms and that you have provided your medical history to the best of your knowledge and agree to ALL terms and conditions.* This field is required.
Clear
Should be Empty: