Do you have a personal or family history of medullary thyroid carcinoma (MTC) *

Yes

Have you ever been diagnosed with MEN2 syndrome? *

Yes

Have you been diagnosed with pancreatitis? *

Yes

Do you have a history of severe GI disease or gastroparesis? *

Yes

Are you currently insulin-dependent? *

Yes

Are you currently taking another GLP-1 medication (e.g. Ozempic, Wegovy, Mounjaro)? *

Yes

Do you have a history of gallbladder disease or gallstones? *

Yes

Do you have significant kidney disease? *

Yes

Do you have a history of an uncontrolled eating disorder? *

Yes

Have you had any major surgery or hospitalization in the last 90 days? *

Yes

Are you currently undergoing active cancer treatment (chemotherapy or radiation)? *

Yes

Do you have any other medical condition you believe may impact your participation in this program? *

Yes

Thank you for completing the screening. Based on your medical history, your intake requires provider review prior to enrollment. This is a routine part of our clinical process — our team will reach out within 24 hours to discuss next steps."

First Name *

Last Name *

Email *

Mobile Phone *

Almost there. Complete your clinical intake below.

Full Name *

Client Date of Birth *

Is your shipping address the same as your billing address?

Yes

Billing Address *

Billing City *

Billing State *

Billing Zip Code *

Shipping Address *

State *

City *

Postal Code *

Tell us about your medical background.

Current Height (cm) *

Current Weight (lb) *

Primary Care Physician (Put None, if Not Applicable)

Current Medications (Put None, if Not Applicable)

Known Allergies (Put None, if Not Applicable)

Past Medical History (Put None, if Not Applicable)

Prior GLP-1 Use *

Additional Notes for Physician

Review and confirm before enrolling.

I attest that: (1) the information provided is true and accurate to the best of my knowledge; (2) I understand my starting dose is determined by the physician, not my tier selection; and (3) I authorize Elyte IV Society to use my protected health information for treatment and program management in accordance with HIPAA regulations.

Select your membership tier.

All tiers include the same physician-directed tirzepatide + levocarnitine protocol. Your tier determines your service level and support. Dose is set by your physician — not your tier. *

The Advanced — $625/mo

The Enhanced — $525/mo

The Standard — $425/mo

The Starter — $349/mo

Before we begin — a few quick questions to confirm this program is right for you.

Thank you for completing the screening. Based on your medical history, your intake requires provider review prior to enrollment. This is a routine part of our clinical process — our team will reach out within 24 hours to discuss next steps."

Tell us what's driving your decision.

Which of the following do you currently experience?

One last question before we get started.

Almost there. Complete your clinical intake below.

Tell us about your medical background.

Review and confirm before enrolling.

Select your membership tier.