This questionnaire is for patients who are NEW to MinuteMD and it will ask you various health-related questions in order to provide you with a number of different weight loss prescription options that are available to you based on your responses. We strive to offer all GLP-1 weight loss options, but please keep in mind that not all options may be available to you based on your responses to the questions. If you are not eligible for treatment with GLP-1 medications, you will be presented with some alternative options.

It is extremely important that you answer the questions honestly.

It is expected that it will take most people approximately 10 minutes to complete this questionnaire and it will require you to provide a picture of a current, non-expired US-government issued photo identification to match the name of the patient.

By my signature above, I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.

Congratulations! Based on your answers, you are conditionally pre-approved for treatment with any of the following product options. Please choose the one which you would prefer and complete the checkout process. Once your order is received, you will hear back from our Care Team within 24 hours (and in most cases, much sooner!) with instructions on your next steps to have your chart reviewed by a provider licensed in your state for prescribing and shipment of your medication.