Find out if you may be a candidate for our physician-supervised GLP-1 weight loss program.
What is your birthdate?
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Where do you live?
*
Street Address
Street Address Line 2
City
Texas
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
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Maine
Maryland
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South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
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State
Zip Code
Reset Solutions can only provide services to patients over the age of 18 in the state of Texas.
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Tell us about your weight loss goals
Besides the number on the scale, what would you most like to change?
Have more energy
Improve my blood pressure, blood sugar, or cholesterol markers
Keep up with my kids or grandkids
Clothes that fit better
Feel more confident
Get stronger
Other
What have you tried before?
Diets or meal plans
Calorie-counting apps
Gym or trainer
Medication
None - this is my first time
Other
What got in the way?
Lost weight but gained it back
Too hard to stick with
Didn't see results
Didn't have anyone to keep me on track
Cost was too expensive
Other
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Tell us about your health
Your answers stay private
What is your current weight?
*
What is your height in feet?
*
Please Select
4
5
6
7
If you are 5 ft 8 inches, enter "5"
What is your height in inches?
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
11
If you are 5 ft 8 inches, enter "8"
BMI
Have you ever taken a GLP-1 to help you lose or maintain your weight? (eg. Wegovy, Ozempic, Zepbound, Mounjaro, Foundayo, Saxenda, semaglutide, tirzepatide)
*
Yes
No
If you have lost weight, what was your highest starting weight?
*
If you're at your highest weight today, then just enter your weight again.
Starting BMI
Has a doctor ever told you that you have any of the following?
*
Pancreatitis
Type 1 diabetes
Type 2 diabetes
Gallbladder disease
Active eating disorder
History or family history of medullary thyroid cancer
MEN 2 syndrome, or family history of MEN 2 syndrome
None of these
Are you pregnant, trying to become pregnant, or breastfeeding?
*
Yes
No
Tell us more about any of the above diagnoses or use of weight loss medications in the past.
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Tell us about your worries and motivation
Is anything holding you back from getting started with a GLP-1 weight loss plan?
Nothing really, I'm ready
I'm not sure it will work for me
I'm not sure if GLP-1s are safe
I'm worried about the cost
I'm not sure how Reset Solutions is difference from other options I've seen
I'm worried I'll lose the weight and gain it back
I'm scared of needles
Other
On a scale of 1-10, how ready are you to get started?
Not ready at all
1
2
3
4
5
6
7
8
9
As ready as I could be
10
1 is Not ready at all, 10 is As ready as I could be
On the readiness scale, why did you rate yourself at that number and not lower?
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Can we contact you?
While only a doctor can make the final determination, we will email you the results of this assessment to let you know if you are a likely candidate for a GLP-1 treatment plan. If we have any questions about your unique health circumstances, our team may reach out via phone call.
What is your name?
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you agree that Reset Solutions may contact you by phone, email or text message to discuss your GLP-1 eligibility?
Yes
No
Lead Qualification
Qualified
Not Qualified
Submit
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