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Let's Get Started

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)
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 Pen(Required)
Semaglutide Prefilled Syringes(Required)
Semaglutide Dissolvable Daily Tablet - ThinneX(Required)
Select One
Tirzepatide Vial(Required)
Tirzepatide Pen(Required)
Select One
Tirzepatide Prefilled Syringes(Required)
Option
Shipping Information
We will deliver medication right to your door.

Payment Information

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