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Your Name(Required)
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LETS START WITH

The Basics

This information helps your healthcare provider determine if you’re eligible for treatment.

Sex Assigned at Birth(Required)

We’re Not Available in Your State Yet

But we’re getting closer! We’re working hard to bring our service to your area soon and will be sure to let you know when we have arrived!

Date of Birth(Required)

Height & Weight

Have you seen your primary care provider in the past 12 months?(Required)
We want to make sure that there’s a healthcare provider outside of us overseeing your overall care.
Do you currently have, or have you ever been diagnosed with, any of the following heart or heart-related conditions?(Required)
Select all that apply
Do you currently have, or have you ever been diagnosed with, any of these hormone, kidney, or liver conditions?(Required)
Select all that apply
Do you currently have any of these conditions?(Required)
Do you currently have, or have a history of, any of these gastrointestinal conditions or procedures?(Required)
Select all that apply
Do you currently have, or have you ever been diagnosed with, any of these additional following conditions?(Required)
Select all that apply
“My weight is negatively impacting my quality of life.”(Required)
Please rate your agreement with this statement.
Because of my weight...(Required)
Select all of the statements that apply to you.
Do you have any allergies to prescription or over-the-counter medicines, herbs, vitamins, supplements, food, dyes etc?(Required)
Our Clinicians use this information in determining a safe and effective treatment.
Our Clinicians use this information in determining a safe and effective treatment.
Do you currently take any of the following medications?(Required)
Select all that apply
Include prescription and over-the-counter medications, herbs, minerals, inhalers, injections, and medication implants or patches.
Our Clinicians use this information in determining a safe and effective treatment.

BEFORE WE WRAP UP

Is there anything else you want your healthcare provider to know about your health?(Required)
Include any additional details about the conditions you’ve already reported.
Which treatment option would you like to explore?(Required)
Select One
Semaglutide Vial(Required)
Semaglutide is the active ingredient used in Ozempic
Semaglutide Pen(Required)
Semaglutide is the active ingredient used in Ozempic
Semaglutide Prefilled Syringes(Required)
Semaglutide is the active ingredient used in Ozempic
Semaglutide Daily Dissolvable Tablet - ThinneX(Required)
Semaglutide is the active ingredient used in Ozempic
Tirzepatide + Glycine + B12 Vial(Required)
Tirzepatide is the active ingredient used in Mounjaro
Tirzepatide Pen(Required)
Select One
Tirzepatide +Glycine + B12 Prefilled Syringes(Required)
Select One
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Tirzepatide Dissolvable Tablet(Required)
Select One
This field is required to allow the Peptides options fields to add price to the peptides selected
Peptides
Shipping Information(Required)
We will deliver medication right to your door.
We have issued a CoverWell Agreement for the services you purchased today, which protects you in the event that you experience a complication. By signing this form, you're agreeing that you are giving up the right to sue this provider in exchange for strict liability and the rapid recovery of specified benefits through CoverWell. In addition, you provide your consent to be contacted by CoverWell by phone and email and waive the HIPAA Authorization Requirement from the service provider(s) by you, the patient. Your CoverWell Agreement will be issued to you via your chosen contact method, email or text. You are the sole recipient of the Agreement. Please save this information; this practice does not receive a copy of your CoverWell Agreement.

Payment Information

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Credit Card(Required)
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Supported Credit Cards: American Express, Discover, MasterCard, Visa
Expiration Date
 
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