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GLP-1 Weight Loss Eligibility
Please complete the pre-screening to determine your eligibility. Those who qualify will gain access to create an account, and submit their order requests.
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1
What is your current weight?
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Pounds
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2
Height (feet)
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3
Height (inches)
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4
BMI Calculation
Underweight: Below 18.5 Healthy Weight: 18.5 – 24.9 Overweight: 25.0 – 29.9 Obesity: 30.0 or higher
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5
Do any of the following apply?
*
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Diabetic retinopathy
Type 1 Diabetic
Low blood sugar
Eating Disorder
HIV/AIDS
Undergoing chemo/radiation or who have undergone chemo/radiation in the last 12 months
Acute inflammation of the pancreas
Decreased kidney function
Medullary thyroid cancer
Medullary tumors or nodules
MEN 2 (Multiple Endocrine Neoplasia Type 2)
Family history of medullary thyroid carcinoma
Kidney disease
Pancreatitis
Pregnant or trying to conceive/start/or add to their family in the next 3 months (both men and women)
Breastfeeding
None of the above
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6
How soon are you looking to begin your weight loss transformation?
*
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Immediately
Within 30 days
Just researching
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7
How would you like to navigate your transformation?
I'm a self starter. (Self-Guided - $220+/month)
I want expert 1-on-1 guidance ($3500+)
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8
Name
*
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First Name
Last Name
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9
Email
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example@example.com
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10
Phone Number
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Please enter a valid phone number.
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