First Name *

Last Name *

Date of birth *

Phone *

Email *

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

Are you currently a patient with us? *

Yes

Billing Address - Full Address *

Billing Address - City *

Billing Address - State *

Billing Address - Zip Code *

Height *

Weight in pounds

Blood Pressure

Allergies *

Current Medications

Current complaint/symptoms

Past Medical Problems *

Surgical History *

Desired Treatment or Medication *

Desired Dosage *

Pharmacy Information

Pharmacy Name *

Pharmacy Address

Pharmacy City *

Pharmacy State *

Pharmacy Zip Code

Pharmacy Phone *

How did you hear about us?

Please upload your ID *

Choose One

General

Weight Management

Please read the patient information and fill out the form below.

GLP-1 therapy is contraindicated in patients with a history of pancreatitis.
GLP-1 therapy is contraindicated for use in patients with type 1 diabetes mellitus.
GLP-1 therapy is contraindicated for patients with a personal or family history of Medullary Thyroid Cancer or Type 2 Endocrine Neoplasia.

The most common side effects of GLP-1 include nausea, diarrhea, decreased appetite, vomiting, constipation, indigestion, headache, and stomach (abdominal) pain. These are not all the possible side effects of GLP-1 use.

👉🏽👉🏽 DO NOT USE/ CONTRAINDICATIONS TO GLP-1 THERAPY:

Do not use GLP-1’s if you OR any of your family have ever had a type of thyroid cancer called medullary thyroid carcinoma (MTC) or Type 2 Endocrine Neoplasia.
GLP-1 therapy is also contraindicated if you have a history of or are currently diagnosed with pancreatitis, kidney disease, or Type 1 diabetes.
GLP-1’s are contraindicated in those who are pregnant, planning to become pregnant, or breastfeeding.
GLP-1 therapy may reduce the effectiveness of your birth control pill. Consider non-oral contraception or add a barrier method after each dose escalation.ext

1. Have you taken GLP-1 in the last 8 weeks? *

Yes

Date of Last Injection *

Please upload a image of your most recent RX label *

name, date of fill and medication dosage must be clearly visible

Are you pregnant, planning to become pregnant, breastfeeding, or bottle-feeding using breast milk? *

Yes, I may be/ am pregnant, planning to become pregnant, or breastfeeding.

Not a chance.

Do you have a personal OR family history of Medullary Thyroid Cancer (MTC), or Type 2 Endocrine Neoplasia (T2EN)? *

Yes, I have a personal history of Medullary Thyroid Cancer (MTC) OR Type 2 Endocrine Neoplasia (T2EN).

No, I have neither a personal OR a family history of Medullary Thyroid Cancer (MTC) OR Type 2 Endocrine Neoplasia (T2EN)

Have you EVER had pancreatitis, kidney or liver disease?

Yes, I have/had pancreatitis, kidney or liver disease.

No, I have NEVER had pancreatitis, kidney or liver disease.

Do you have an active cancer diagnosis, OR have you undergone cancer treatment within the past 6 months?

Yes, I currently have an active diagnosis of cancer OR have undergone cancer treatment within the past 6 months

No, I do NOT have an active diagnosis of cancer AND have not been treated for cancer within the past 6 months.

Do you have a history of organ transplant and/or currently on immune-suppressing medication?

Yes, I have a history of organ transplant and/or use immunosuppressing medications.

I have NO history of organ transplant or use immunosuppressing medications.

Do you have OR have you EVER had a severe or chronic gastrointestinal condition? (such as, but not limited to: bowel obstruction, gastroparesis, etc.)

Yes, I have had in the past or currently have a severe or chronic gastrointestinal condition.

No, I do NOT have and have NEVER had a severe or chronic gastrointestinal condition

Have you had bariatric surgery within the past 1 year?

Yes, I HAVE had bariatric surgery within the past year.

No, I have NOT had bariatric surgery within the past year.

Have you been diagnosed with Type 1 Diabetes, typically diagnosed during childhood?

Yes, I have been diagnosed with Type 1 Diabetes.

b. No, I do NOT have Type 1 Diabetes.

Have you been diagnosed with Type 2 diabetes? *

Yes, I have been diagnosed with Type 2 Diabetes and am NOT on insulin.

Yes, I have been diagnosed with Type 2 Diabetes and AM on insulin.

No, I have NOT been diagnosed with Type 2 Diabetes.

Are you aware that most insurances will NOT cover GLP-1 medications without meeting very specific criteria? *

Yes

Your information will be forwarded to the care team. Please expect to hear from them shortly via secured messaging. Hit Submit below