Do you qualify for the Semaglutide Protocol?

*Get approved 100% online for the only holistic semaglutide program designed to support both short and long term weight loss in as little as five minutes

What is your gender? *

Male

Female

Are you pregnant or planning to become pregnant in the next six months?

Yes

What is your weight loss goals? *

Yes

Is your Body Mass Index over 25? *

Yes

Do you experience high blood pressure? *

Yes

Do you take prescription oral medications for high blood pressure?

Yes

Do you or your family have a history of pancreatitis? *

Yes

Do you suffer from PCOS Polycistic Ovarian Disease? *

Bloating

Stomach pain/cramps

Irregular bowel movements

Constipation

Diarrhea

Nausea

Heartburn/reflux

None of the above

Do you have a history of Acute Kidney Injury (AKI) or End-stage Renal Disease (ESRD)? *

Yes

Have you been diagnosed with Pre-Diabetes or Type 2 Diabetes? *

Yes

Do you take any oral anti-diabetic medications? If so, please name them here:

Do you have a history of diabetic retinopathy?

Yes

Have you been diagnosed with Type 1 Diabetes? *

Yes

Do you have Sleep Apnea or any sleeping disorder? *

Yes

Do you have Non Alcoholic Fatty Liver Disease? *

Yes

Do you have a family history of heart disease or high cholesterol? *

Yes

Do you or any family members have a history of thyroid cancer including Medullary Thyroid Carcinoma (MTC) or Multiple Endocrine Neoplasia Syndrome Type 2 (MEN 2)? *

Yes

First Name

Last Name

Date of birth

Phone

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