First Name

Last Name

Email *

Important: Use the same email used to place your order

Phone *

Date of Birth *

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What is your height? (ft/in) *

What is your weight? (In pounds) *

Can you share your most recent blood pressure reading or an estimate of your typical range? (For example, 120/70)? *

Are you currently? *

Pregnant

Planning to become pregnant

Breastfeeding

None of the above

Have you injected a GLP-1 medication in the past 30 days? *

YES

Not within 30 days, but previously

I have never taken GLPs

Which weight loss medication are you currently taking? *

Semaglutide (Wegovy, Ozempic, Compounded)

Tirzepatide (Mounjaro, Zepbound, Compounded)

Liraglutide (Saxenda)

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Which weight loss medication have you previously taken? *

Semaglutide (Wegovy, Ozempic, Compounded)

Tirzepatide (Mounjaro, Zepbound, Compounded)

Liraglutide (Saxenda)

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REQUIRED - Please upload an image of your most recent vial or prescription

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Skip - I don’t have it

Upload an image of your most recent vial or prescription

Depending on state regulations, your provider may reach out to you to perform a consultation over the phone. otherwise, your provider will review your intake forms and approve your script if all criteria are met. *

I understand that my provider will reach out via phone if they think it is necessary to get additional information from me.

Patients must meet specific criteria to qualify for compounded GLP medications. Eligibility requires demonstrating a clinical justification that commercially available medications are not appropriate based on the patient's individual needs. *

I UNDERSTAND

Based on your responses, you may qualify for compounded GLP medications. Please be aware that compounded medications may have dosing that differs from commercially available products to better meet individual patient needs. *

I UNDERSTAND

Signature *

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Upload a valid government-issued photo ID (e.g., driver’s license or passport) *

Upload a valid government-issued photo ID (e.g., driver’s license or passport)