GLP-1 Telehealth Intake

1
US State* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
Full legal name* This field is required.
First Name
Middle Name
Last Name
4
Date of birth* This field is required.
Date
Month
Day
Year
5
Phone number* This field is required.
Please enter a valid phone number.
6
Email address* This field is required.
example@example.com
7
Full address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / 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
8
Government ID photo upload
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Max. file size: 10.0MB
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9
Height – feet* This field is required.
10
Height – inches* This field is required.
11
Current Weight (lbs)* This field is required.
12
Goal Weight (lbs)
13
Recent Weight Trend* This field is required.
Please Select
Please Select
Gaining
Stable
Losing
14
Current medications
15
Do you take any of these?* This field is required.
Insulin
Sulfonylurea
Other diabetes med
Blood thinner
None
16
If Other, describe
17
Are you 18 or older?* This field is required.
Yes
No
18
Non-emergency weight management. Understand?* This field is required.
Yes
19
Selfie (optional)
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Max. file size: 10.0MB
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20
New to GLP-1 or transferring?* This field is required.
New
Transferring
21
Prior weight-loss medications
22
Allergies
23
Have you used a GLP-1 medication before?* This field is required.
Yes
No
24
If yes, please describe which medication, dose, how long you used it, and any side effects experienced
25
Prior side effects experienced
Nausea
Vomiting
Diarrhea
Constipation
Other
26
Personal history of medullary thyroid carcinoma?* This field is required.
Yes
No
27
Family history of medullary thyroid carcinoma?* This field is required.
Yes
No
28
Personal or family history of MEN2?* This field is required.
Yes
No
29
History of pancreatitis?* This field is required.
Yes
No
30
Severe gastrointestinal disease or gastroparesis?* This field is required.
Yes
No
31
Currently pregnant, breastfeeding, or planning pregnancy?* This field is required.
Yes
No
32
Known hypersensitivity to GLP-1 medications?* This field is required.
Yes
No
33
Prior weight-loss attempts
34
Biggest barriers to weight loss
35
Readiness to begin treatment* This field is required.
Please Select
Please Select
Ready now
Within 1 month
Within 3 months
Not sure
Other
36
What motivates you to pursue treatment?
37
Recent lab results
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38
Current medication list
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39
Progress photos
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40
Telehealth Consent* This field is required.
41
Treatment Consent* This field is required.
42
Medication Risk Consent* This field is required.
43
Communication Consent* This field is required.
44
Payment* This field is required.
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ORDER SUMMARY
Total costUSD
First Month
GLP-1 telehealth program - first month
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Monthly Plan
GLP-1 telehealth program - ongoing monthly fee
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$130 per month
Per month
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$345 3-mo
3-month plan
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$594 6-mo
6-month plan
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Total
45
Financial & Cancellation Consent* This field is required.
Should be Empty: