Welcome to STL MED! To continue, you must agree to a $49 telehealth consult fee after you complete the form. Do you want to proceed?
Yes — I agree and want to proceed.
No — not at this time.
Telehealth Form
(No Phone Call or Video Visit Required- Based on Responses Below)
First Name
*
Last Name
*
Street Address
*
State
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
DC
City
*
Zip Code
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Current Weight (in lbs)
*
How much weight do you want to lose? (in lbs)
*
Please list any medications you take:
Please list any allergies
Medical History Select any Diagnoses that apply:
Diabetes
High Blood Pressure
High Cholesterol
Fatty Liver Disease
PCOS
Pre-Diabetes
Insulin Resistance
None of the Above
Do you have any personal or family history of Thyroid Cancer or MEN2
YES
NO
History of Pancreatitis
YES
NO
Pregnancy/breastfeeding/planning pregnancy
YES
NO
Any History of Stomach or Kidney Conditions (CKD, Chronic Kidney Disease)
YES
NO
Any History of Bariatric Surgery?
YES
NO
Do you take insulin or sulfonylureas like GLYBURIDE or GLIPIZIDE or GLIMEPIRIDE?
YES
NO
Have you had blood work/labs in the last 12 months.
*
YES
NO
If you answered YES, were there any abnormalities noted?
Are you willing to follow guidance and understand this is a long term plan to help you lose weight?
YES
NO
What weight loss medications have you tried in the past? Please LIST the NAME and DOSE.
*
Date of LAST DOSE:
What weight loss medication are you interested in? Please LIST BELOW
*
Signature: Telehealth & Treatment Consent, I understand that this evaluation and treatment are being provided via telehealth, including asynchronous review of my medical information. I acknowledge that GLP-1 medications and other peptides have potential risks, benefits, and alternatives, which I have reviewed or may review upon request. I consent to treatment if approved and agree to follow prescribed instructions and report any adverse effects.
*
Submit
Should be Empty: