How do you want us to call you? *

We need some information so we can contact you later

Phone *

Email *

Customer Acknowledgement & Terms of Service

Please review the following important information. By checking the box and proceeding, you confirm your understanding and agreement with the terms outlined below.

Fulfillment Timeline

I acknowledge that pharmacy fulfillment typically takes 7–10 business days, although delivery may occur sooner depending on availability and logistics.

Return Policy

I understand that if prescribed, this medication is custom-prepared specifically for me and therefore not eligible for return under any circumstances.

Order Cancellation Policy

Once a prescription (eRx) has been issued and sent to a partner pharmacy, I understand that my order cannot be changed. While Slimmer U. Rx will attempt to cancel the order upon request, no guarantee is made. If a cancellation is successful, I agree that a $100 nonrefundable clinical and consultation fee will be withheld from my refund.

Customer Responsibility

I confirm that I am solely responsible for accurately completing the medical intake form. My responses will be used by a licensed provider to determine the appropriateness of treatment. I understand that misrepresentation may impact the safety or effectiveness of my care.

Order Processing Acknowledgment

I understand that by enrolling and proceeding, I am authorizing processing of my order and initiation of clinical review.

Treatment Risks & Financial Responsibility

I acknowledge that all medical treatments involve some risk of side effects or adverse outcomes, including potential pregnancy. These risks do not release me from the financial responsibility for the prescribed medication, even if the treatment must be discontinued before completion. I understand that no outcomes are guaranteed, and all prescriptions are nonrefundable.

Disclaimer & Trademark Notice

Slimmer U. Rx may prescribe GLP-1 medications such as Ozempic®, Wegovy®, Zepbound®, Mounjaro®, and others when appropriate.

These medications are among the most effective options for weight management.

Compounded versions may also be offered when deemed medically appropriate.

Compounded medications are not FDA-approved and do not undergo federal review for safety, effectiveness, or manufacturing standards.

Slimmer U. Rx is not affiliated with Novo Nordisk or Eli Lilly, the trademark holders of these medications.

Refill Policy & Consent

By enrolling in this program, I authorize my healthcare provider to issue prescription refills as medically appropriate to avoid gaps in treatment.

I understand I can pause, skip, cancel, or check in with my provider at any time via my patient dashboard.

My credit card will be charged at the time of each refill.

Once a refill has been processed or dispensed, it cannot be canceled, returned, or refunded.

Do you agree with the above conditions? *

Yes

Please add your signature here if you agree *

Clear

What's your weight loss goal? *

Lose 5 to 20 lbs

Lose 21 to 50 lbs

Lose 51+ lbs

Not sure

Losing weight with Slimmer U. Rx—No calorie counting, no gym required.

Discover a simpler, science-backed way to shed weight—without the stress of restrictive diets or intense workouts.

To see if you’re a candidate for treatment, just answer a few quick questions about your health and wellness goals.

Ready to get started?

How the Process Works with Slimmer U Rx

Complete a Quick Online Questionnaire
Share your health goals and medical history—all from the comfort of your home.
Physician Review
A licensed healthcare provider will carefully evaluate your information and determine your eligibility for treatment.
Fast, Secure Delivery
If approved, your personalized medication is shipped the next business day from a certified U.S. pharmacy.
Ongoing Support, Anytime
Get unlimited access to follow-ups, treatment adjustments, and expert answers through our easy-to-use online portal.

Are you currently pregnant/breastfeeding/planning to become pregnant? *

Yes

Pregnancy & Breastfeeding Safety Acknowledgment

Please review the important precautions below regarding pregnancy and breastfeeding before starting treatment.

This medication may pose risks to individuals who are pregnant, nursing, or planning to conceive. It is not recommended during pregnancy or while breastfeeding, and may reduce the effectiveness of oral contraceptives.

Read the following carefully to understand how this treatment may affect you, and speak with your healthcare provider if you have questions or concerns.

⚠️ Important Pregnancy & Breastfeeding Precautions

For your safety and that of your child, GLP-1 and similar weight loss medications are not recommended during pregnancy or while breastfeeding. These medications may pose risks to a developing fetus, and their safety during lactation has not been established.

Contraception Guidance:

Oral contraceptives alone may not be reliable while on this medication. It is recommended that you use a barrier method (e.g., condoms) in combination with oral birth control during the first month of treatment and after any dosage increase.
Alternatively, consider switching to a non-oral contraceptive method (e.g., IUD or implant) before starting the medication.
After stopping treatment, continue using a backup contraceptive method for at least two months to ensure the medication is fully cleared from your system before trying to conceive.

If You Are Breastfeeding:

The safety of this medication while nursing is unknown. Speak with your healthcare provider to explore alternative weight loss options that are safer during breastfeeding.

By continuing, you acknowledge that you have read and understand the safety information provided.

What is your Weight? *

lbs

What is your Height? *

What is the highest weight you’ve ever recorded? (Please provide an approximate number, if unsure.) *

lbs

BMI & Off-Label Use Consent

Please review the information below regarding eligibility and the use of this treatment based on your BMI.

Important Information

The traditional use of weight loss medications is for individuals with a BMI of 30 and above or to those who are overweight who have associated health conditions.

Using it for someone with a BMI range (27-29) without an accompanying health condition is termed "off-label."

Using a medication "off-label" refers to the practice of prescribing a drug for a purpose, age group, dosage, or form of administration that is not included in the approved labeling by regulatory agencies like the U.S.

Food and Drug Administration (FDA). While a medication undergoes rigorous testing for specific uses before receiving approval, healthcare providers may discover through clinical experience or research that it can be effective for treating other conditions.

There may be benefits such as weight reduction for individuals within your range. If you agree to this off-label use, it's crucial to follow the prescribed regimen and report any concerns.

Please discuss any questions with us.

By continuing, you acknowledge that:

You understand this treatment may be prescribed off-label based on your BMI and individual health profile.
You agree to follow your provider’s recommendations and treatment plan.
You will promptly report any side effects or concerns during the course of your treatment.

Do you acknowledge? *

Yes

*If you have questions, please don’t hesitate to reach out to your care team—we’re here to support you.

When were you first diagnosed as overweight or obese? Select the option that best applies to you: *

Last Year

This year

Long time ago

Not sure

How would you describe your current approach to managing your weight? Select the option that best reflects your current efforts: *

I’m actively managing my weight (e.g., through diet, exercise, or medical support)

I’m making some efforts, but not consistently

I’m not currently taking any active steps

How would you rate your current level of physical activity? *

Sedentary: Little to no structured physical activity

Light: Occasional walking or light exercise

Moderate: Regular activity like walking, cycling, or light workouts several times a week

Vigorous: Intense exercise such as running, strength training, or sports multiple times per week

Select the option that best describes your typical activity level

Are you currently following a specific dietary plan? *

None: I’m not following any specific diet or plan

Minor Modifications: I’ve made small changes, like reducing sugar or portion sizes

Significant Changes: I’m following a structured diet (e.g., low-carb, intermittent fasting, meal plans)

Select the option that best describes your current approach to eating

Have you undergone gastric bypass surgery within the past 6 months? *

Yes

Allergy Screening

Are you allergic to any of the following? *Please select all that apply, or choose “None of the above” if none are relevant.

Current Medication Check

Insulin, glimepiride (Amaryl), glipizide (Glucotrol and Glucotrol XL), glyburide (Micronase, Glynase, and Diabeta), sitagliptin, saxagliptin, linagliptin, and alogliptin

Do you currently take any of the following medications? *

Yes

(These medications may interact with certain weight loss treatments.)

Recent Medication Use

Are you currently taking—or have you taken within the past two months—any of the following medications? *

Semaglutide (Ozempic, Wegovy, Rybelsus)

Tirzepatide (Zepbound, Mounjaro)

None of these

If applicable, a list of specific medications will follow this question for selection.

Injection Comfort & Support

Do any of the following apply to you?

Fear of needles
Difficulty tolerating injections
Inability to consistently receive help with administering injections
Vision limitations that make self-injection unsafe

Please select the option that best reflects your situation *

Yes – I would prefer an oral formulation due to one or more of the concerns above

No – I am comfortable with injections and/or have reliable support for administration

Medication Sensitivity

Everyone responds to medications differently.

Do you typically experience side effects from standard medication doses and often require lower doses to tolerate treatment safely? *

Yes – I am generally sensitive to medications and usually need lower doses

No – I usually tolerate standard medication doses without significant side effects

Not sure – I’m uncertain how I typically respond to medications

Your Dosing Options

Our medical team has not yet reviewed your full intake form, but based on your responses, you may be eligible for a brand name medication.

As experienced providers, we’ve also developed an alternative dosing protocol that may offer a more gradual and comfortable experience—especially for those who are new to this treatment or more sensitive to side effects.

How would you prefer to proceed? *

I’d like to follow the standard brand name dosing protocol

I’d like to try the alternative dosing protocol recommended for comfort and tolerance

If you’re unsure, feel free to contact our care team—we’re here to guide you every step of the way.

Allergy Information

Please include any allergies to:

Prescription or over-the-counter medications (e.g., antibiotics, pain relievers, allergy meds)
Herbs, vitamins, or supplements
Foods or food additives
Dyes or preservatives
Environmental allergens or any other substances

Do you have any known allergies? *

Yes – I have allergies (please list below):

No known allergies

If yes, please list all of your allergies.

Do you have any current medical conditions, a history of prior surgeries, or any other health details you'd like your provider to know? *

Yes

Current Medication Use