Telehealth Form

  • Telehealth Form

    (No Phone Call or Video Visit Required- Based on Responses Below)
  •  - -
  • Format: (000) 000-0000.
  • How much weight do you want to lose?*
  • Medical History Select any Diagnoses that apply:
  • Do you have any personal or family history of Thyroid Cancer or MEN2
  • History of Pancreatitis
  • Pregnancy/breastfeeding/planning pregnancy
  • Any History of Stomach or Kidney Conditions (CKD, Chronic Kidney Disease)
  • Any History of Bariatric Surgery?
  • Do you take insulin or sulfonylureas like GLYBURIDE or GLIPIZIDE or GLIMEPIRIDE?
  • Have you had blood work/labs in the last 12 months.*
  • If you answered YES, were there any abnormalities noted?.
  • Have you previously taken a GLP-1 : Semaglutide or Tirzepatide?
  • Select the weight loss medication you are interested in:*

  • Great News — You’re Pre-Approved!

    To finalize your submission and have your information reviewed by the doctor, please complete the

    $19.99 consultation fee below.

    Once payment is completed, your intake will be immediately submitted for physician review.

  • IF APPROVED-

    You selected SEMAGLUTIDE, your CARD WILL BE CHARGED for $299/mo.

  • IF APPROVED-

    You selected TIRZEPATIDE, your CARD WILL BE CHARGED for $399/mo. 

  • Should be Empty: