BEFORE YOU ORDER!
Which would you like to be screened for?
Tirzepatide
Retatrutide
Both
Not sure yet
Let's start with the basics
First Name
Last Name
Email
*
Phone
*
Date of birth
*
State
*
Sex assigned at birth?
*
Male
Female
Are you currently pregnant, breastfeeding, or trying to get pregnant?
*
Yes
No
A quick safety check
Have you or anyone in your immediate family ever been diagnosed with medullary thyroid cancer (MTC), or with Multiple Endocrine Neoplasia syndrome type 2 (MEN2)?
*
Yes
No
I'm not sure
Have you ever been diagnosed with Cancer?
*
Yes, currently in treatment
Yes, previously
No
Are you currently experiencing pancreatitis?
*
Yes
No
Your Height (Feet)
*
Your Height (Inches)
*
Your Weight (lbs)
*
Your health history
Do you have any of these?
*
Type 1 diabetes
Type 2 diabetes.
Thyroid disease
Kidney or liver disease
Heart disease
High blood pressure
High cholesterol
PCOS
Gallbladder disease
Stomach/gut disease
Depression or anxiety
None of These
What medications do you currently take?
Any allergies to medication?
When did you last see a doctor?
*
Within a year
1-3 years
3+ years
Never
One more health question
Have you ever experienced an eating disorder?
*
Yes, currently
Yes, in the past
No
Prefer not to say
Your Goal
What's your current goal weight?
*
Have you tried this before?
Have you used a weight-loss medication before, such as Ozempic, Wegovy, Mounjaro, or Zepbound?
*
Yes
No
About that medication
Which medication was it?
When was your last dose?
Why did you stop?
*
Side effects
Cost
It wasn't working
I reached my goal
Supply issues
Other
A bit about your lifestyle
How active are you day to day?
*
Not very active
Somewhat active
Very active
Do you drink alcohol?
*
Never
Sometimes
Weekly
Daily
Do you use nicotine?
*
No
Vape
Cigarettes
Other
Are you comfortable giving yourself a small injection once a week?
*
Yes
No
Almost Done