MinuteMD GLP-1 Initial Enrollment Form

1
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 by the patient who will be receiving the medication once prescribed.

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.

Once you complete the questionnaire, you will be presented with treatment options which you pre-qualify for based on your responses to the following questionnaire.
2
What is the patient's full name (as it appears on US-government issued photo ID)?* This field is required.
First Name
Last Name
3
What is the patient's date of birth?* This field is required.This must match the patient's date of birth on photo identification.
Date
Month
Day
Year
4
What is the patient's email address?* This field is required.Please enter it twice to confirm accuracy. This is extremely important to be able to receive all notifications.This MUST be the patient's email address due to HIPAA patient privacy laws.
example@example.com
Confirm Email For Accuracy
5
What is the patient's best phone number if the providers have any questions?* This field is required.
Please enter a valid phone number.
6
Do you consent to receiving order status updates via text messaging?* This field is required.
7
What is the patient's shipping address?* This field is required.This is the address where the pharmacy will ship the order once approved.Medication can only be shipped to the patient's name directly and not to a third party.
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
State
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
Please take a photo of your government issued photo ID. Failure to provide this now may delay your order and our customer service team will reach out to you to provide this within 24 business hours. Our providers require unexpired government issued photo ID to treat patients (Drivers License/Passport).
9
Are you currently taking, or have taken in the last 2 months, any GLP-1 agonist medication?* This field is required.These medications include semaglutide (Ozempic®, Wegovy®, Rybelsus), tirzepatide (Mounjaro®, Zepbound®) or liraglutide.
Please Select
Please Select
Yes, I currently am taking one of these medications and have taken my last dose within the last 2 months.
No, I do not currently take any GLP-1 medication.
10
Which medication are you currently taking, or have taken in the last 2 months?* This field is required.
Please Select
Please Select
Semaglutide/Ozempic/Wegovy
Tirzepatide/Mounjaro/Zepbound
Liraglutide
11
What dosage most closely matches your most recent dose of Semaglutide/Ozempic®/Wegovy®?* This field is required.
Not Applicable
Please Select
0.25mg/week
0.50mg/week
1.0mg/week
1.7mg/week
2.5mg/week
You will be prompted to upload a photo of your current prescription to validate your chosen dosage.
12
What dosage most closely matches your most recent dose of Tirzepatide/Mounjaro®/Zepbound®?* This field is required.
Not Applicable
Please Select
2.5mg/week
5mg/week
7.5mg/week
10mg/week
12.5mg/week
15mg/week
You will be prompted to upload a photo of your current prescription to validate your chosen dosage.
13
Have you experienced side effects from your current medication?* This field is required.Select all that apply, or select No if you have not experienced any side effects from your current medication.
Yes, I experienced fatigue.
Yes, I experienced nausea.
Yes, I experienced muscle loss.
Yes, I experienced other side effect(s).
No, I did not experience any side effects.
14
Please describe your side effects in more detail for your provider:
15
Would you like to explore the possibility of an additive which may help manage the side effects you have mentioned above?* This field is required.
YESNO
16
How are you doing on your current medication?* This field is required.
I'm not feeling the effects of this medication and NOT losing weight, and I am NOT having side effects.
I'm not feeling the effects of this medication and NOT losing weight, but I AM having side effects.
I am feeling the effects of this medication and AM losing weight (1-2lbs/week), and NOT having side effects.
I am feeling the effects of this medication and AM losing weight (1-2lbs/week), but I AM having side effects.
17
Would you like to increase to a higher dose?* This field is required.
Yes, I would like to request an increase to the next medically appropriate dosage.
Yes, and I would like to request a rapid titration protocol which allows the dosage to increase faster.
No, I do not want to request a higher dosage.
18
Would you like to attempt to mitigate these side effects by taking a smaller dose twice per week?* This field is required.
Yes, I would like to take a smaller dose twice per week instead of a larger dose once per week to attempt to mitigate these side effects.
No, I would like to stick to taking this medication at my current frequency.
19
Please take a photo of your current GLP-1 prescription to validate your choice above. It should include your name, medication name, date of prescription, and prescribed dosing instructions. Failure to provide proof of current prescription will result in the lowest dosage being prescribed.
20
What was your sex assigned at birth?* This field is required.
Male
Female
21
Are you currently pregnant, breastfeeding, or planning to become pregnant?* This field is required.
Yes
No
22
Please read the statement below and indicate your understanding and consent only if you agree and wish to continue with this treatment.* This field is required.If you do not agree, please close this questionnaire and do not continue.
23
What is the highest weight you have ever reached?* This field is required.
24
Please enter your current height and weight:* This field is required.
25
Actual Calculated BMI
26
Please read the statement below and indicate your understanding and consent only if you agree and wish to continue with this treatment.* This field is required.If you do not agree, please close this questionnaire and do not continue.
27
When were you first diagnosed with being overweight or obese?* This field is required.
Please Select
Please Select
Within the last year
1-5 years ago
More than 5 years ago
Unsure
28
How would you describe your current approach to weight management?* This field is required.
Please Select
Please Select
Actively managing
Some efforts
No active efforts
29
How would you rate your current activity level?* This field is required.
Please Select
Please Select
Sedentary (I don't exercise)
Light
Moderate
Vigorous
30
What dietary plan, if any, are you currently following?* This field is required.
Please Select
Please Select
None
Minor modifications
Significant dietary changes
31
Please check ALL current or past medical conditions:* This field is required.Choose "NONE OF THE ABOVE" if none of these choices are applicable.
Gastroparesis
Triglycerides over 600 at any point
Pancreatic cancer
Pancreatitis
Type I diabetes
Hypoglycemia
Insulin-dependent diabetes
Thyroid cancer
Family history of thyroid cancer
Family history of Multiple Endocrine Neoplasia (MEN-2) syndrome
Anorexia or bulimia
Current symptomatic gallstones
Gallbladder removed
Hypertension (high blood pressure)
Dyslipidemia (high cholesterol or triglycerides)
Liver disease or conditions that effect the liver
Heart disease or conditions that effect the heart
Metabolic syndrome
Chronic Kidney Disease Stage 3 (or greater)
Syndrome of Inappropriate Antidiuretic hormone
Hypothyroidism, Hyperthyroidism or other Thyroid issues
Type II diabetes
NONE OF THE ABOVE
32
Gallbladder Disclaimer* This field is required.
33
Please tell us more about your medical condition(s):* This field is required.You indicated one or more current or previous medication conditions above. Please tell us more information about each condition that you indicated was applicable to you.
34
Have you had a gastric bypass in the past 6 months?* This field is required.
Yes
No
35
Are you allergic to any of the following medications?* This field is required.Check all that apply, or if you have no allergies to these medications, check "None of the Above".
Ozempic (Semaglutide)
Mounjaro (Tirzepatide)
Wegovy (Semaglutide)
Zepbound (Tirzepatide)
Saxenda (Liraglutide)
Trulicity (Dulaglutide)
None of the Above
36
Do you currently take any of the following medications?* This field is required.Check all that apply, or if you do not take any of these medications, check "None of the Above".
Insulin
Glimepiride (Amaryl)
Meglitinides such as repaglinide or nateglinide
Glipizide (Glucotrol and Glucotrol XL)
Glyburide (Micronase, GLynase, Diabeta)
Sitagliptin
Saxagliptin
Linagliptin
Alogliptin
None of the Above
37
Do you have any allergies (food, medicine, or both)? If yes, list all allergies and your reactions to each. If no, write NO.* This field is required.
38
Please list ALL prescription medications you are currently taking, if any. If none, write NONE.* This field is required.
39
Do you have a fear of needles, unable to tolerate injections, unable to have someone consistently help with the injection, or unable to see the syringe to safely draw the correct dosage and inject a medication?
Yes, I'm not a good candidate for injections and would like an oral formulation for a safer experience.
No, I am capable of injecting myself and/or have someone who can consistently help me.
40
People have sensitivities to medications and commonly experience side effects to standard dosing regimens. Do you commonly experience side effects to medications and often require lower doses to avoid side effects?* This field is required.
YESNO
41
What dosage protocol do you prefer?* This field is required.Our providers have not yet reviewed your intake form, but you may be a candidate for a brand name product which we are happy to provide. Based on our experience as providers, we have developed an alternative dosing protocol which may provide a more comfortable experience for you. How would you like to proceed?
I would like to stick with the established brand name dosing protocol.
I would like to try to the alternative dosing protocol.
42
Do you have any additional medical information that you feel would be helpful for your provider to know when reviewing your information and lab results? Use this space to describe if needed.
43
Patient Signature* This field is required.By my signature below, 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 are 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.
Clear
44
Compounded GLP-1 Medication Disclaimer* This field is required.If you do not agree with the statement below, please close this questionnaire and do not continue.
45
Which medication are you interested in being prescribed?* This field is required.Based on your answers provided, you are conditionally pre-qualified for treatment with one of the following programs.
Weight Loss Program (Compounded Semaglutide) - $249/month
Weight Loss Program (Compounded Tirzepatide) - $399/month
46
Which medication are you interested in being prescribed?* This field is required.Based on your answers provided, you are conditionally pre-qualified for treatment with one of the following programs. If you do not see your expected product(s) here, one or more of your previous answers may prevent it from being available.
Weight Loss Program (Wegovy®) - $1,299/pen
Weight Loss Program (Zepbound™) - $1,499/pen
47
Patient Consent (Verification)I verify that I am the patient and that I have answered the questions asked in this intake form. 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 provided.
I have read the above information and I do consent and wish to move forward.
I have read the above information and I do not wish to continue.
48
Patient Consent (GLP-1 and GLP-1/GIP Treatment)* This field is required.You are requesting treatment with a GLP-1 (Ozempic, Wegovy, or compounded semaglutide) or GIP/GLP-1 receptor agonist (Mounjaro, Zepbound or compounded tirzepatide) medication as part of your treatment plan for the management of weight or obesity. These medications work by mimicking the action of incretin hormones, which help regulate blood sugar levels, promote feeling full, and reduce food intake.Potential Benefits:- Weight loss or weight management- Improved blood glucose control- Reduced cardiovascular risk- Potential improvement in overall metabolic healthPotential Side Effects:Common side effects include nausea, vomiting, diarrhea, constipation, decreased appetite, indigestionSerious Side Effects:Pancreatitis, hypoglycemia, gallbladder disease, kidney problems, allergic reactions, gastroparesisRisks & Considerations:Pancreatitis: There is a risk of developing pancreatitis. If you experience severe abdominal pain, nausea or vomiting, you should contact your healthcare provider immediately.FDA Approved Brand Name Medications:Zepbound, Mounjaro, Ozempic, WegovyCompounded Medications:For patients who may benefit from a more specialized approach, we offer compounded formulations of semaglutide and tirzepatide. These compounded medications can be customized with alternative dosing schedules, alternative dosing frequencies, different routes of administration and/or additives intended to help reduce side effects commonly seen with the brand name products.Compounded medications are custom-prepared by licensed pharmacists to better meet an individual patient's specific needs. Unlike FDA-approved brand name products, compounded medications are not subject to the same rigorous testing and extensive clinical trials. This means that while they offer the advantage of customization, there may be differences in the consistency, efficacy and safety profiles compared to those of the branded products.By continuing with this treatment plan, you acknowledge that:- You have been informed of the available treatment options, including both FDA-approved brand name medications and compounded alternatives.- You understand that compounded medications are tailored to meet individual needs but are not subjected to the same level of testing as brand name products.- Your treatment plan will be determined based on your candidacy and specific health requirements, ensuring the most appropriate therapy for you.Please review this information carefully and reach out to our support team if you have any questions before proceeding.
I have read the above information and I do consent and wish to move forward.
I have read the above information and I do not wish to continue.
49
Thank you!

This completes your initial pre-qualification questionnaire. Please click the SUBMIT button on this page to complete your submission, at which time your will be analyzed to see if you are qualified to be treated through our weight loss program.

If approved, you will be redirected to a page where you will complete the checkout process to begin your treatment with us. Once payment has been completed on that screen, you will receive an email with the next steps to get started.

Thank you for trusting MinuteMD with your health, and we look forward to working with you!
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