The 30 Day Remedy Reset Challenge
This form is for pre-screening purposes only and does not guarantee eligibility or prescribing. Final determination will be made by a licensed medical provider.
Patient Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
DOB:
*
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Eligibility Screening
What is your current Body Mass Index (BMI)?
*
BMI 30 or greater
BMI 27–29.9
BMI below 27
If your BMI is 27 or greater, do you have any of the following weight-related medical conditions?
*
Hypertension (high blood pressure)
High cholesterol
Polycystic Ovary Syndrome (PCOS)
Type 2 diabetes
None of the above
If your BMI is below 27, do you have any of the following metabolic or weight-related factors that may warrant further medical review?
*
Polycystic Ovary Syndrome (PCOS)
Insulin resistance or prediabetes
History of gestational diabetes
Metabolic syndrome
Hormonal weight gain
None of the above
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Weight History & Prior Treatment
How long have you struggled with weight management?
*
Less than 1 year
1–5 years
More than 5 years
Have you previously used prescription weight loss medications or GLP-1–based therapies (e.g., semaglutide, tirzepatide)?
*
Yes
No
If yes, please list medication(s), approximate duration, and any side effects experienced.
What is your primary goal for this 30-day program?
*
Please Select
Appetite Control
Weight loss
Portion control
Jump-starting lifestyle changes
Other
If selected other, please explain here:
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Medical History
Have you ever been diagnosed with or treated for any of the following?
*
Type 1/2 diabetes
Pancreatitis
Kidney Disease
Gallbladder disease
Chronic gastrointestinal conditions
Thyroid nodules or cancer
Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
Medullary thyroid carcinoma (MTC)
Liver disease
Eating disorder (past or present)
Hypoglycemia (low blood sugar)
None of the above
If any selected: Please provide details (diagnosis, year diagnosed, current status).
Please list all current prescription medications:
*
Are you currently pregnant, breastfeeding, or planning to become pregnant in the next 2 months?
*
Yes
No
Are you currently taking insulin or insulin-stimulating medications?
*
Yes
No
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Acknowledgment & Consent
By checking the boxes below, you acknowledge that you have read, understand, and agree to the following statements.
*
I understand tirzepatide is a prescription medication and participation requires medical approval.
I understand potential side effects may include nausea, decreased appetite, constipation, or fatigue.
I agree to follow provider guidance and report concerning symptoms promptly.
I understand that this is a 30-day weight loss challenge requiring weekly in-person visits (a total of 4 visits).
I understand that tirzepatide injections will be administered in-office at each scheduled visit and will not be provided for self-administration at home.
I understand that attendance at all scheduled appointments is required to participate in this challenge.
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