What state do you live in?

We need this to match you with a licensed provider in your state.

What is your current height and weight?

We'll calculate your BMI to check your eligibility

What is your weight loss goal?

This helps us determine the best treatment plan for you.

Have you undergone bariatric or gastric bypass surgery?

This helps us ensure your safety and determine the best treatment option

Do you have any of these conditions?

This helps us ensure your safety

Do you have any other medical conditions not already listed?

Be as specific as possible with any relevant details

Please describe your other medical conditions

Do any of these apply to you?

These conditions may affect your eligibility for treatment

Are you currently taking any of these medications?

Select all that apply

Have you taken a GLP-1 medication before?

This helps us personalize your starting dose so you don't have to re-titrate from scratch.

Which GLP-1 medication were you on?

What was your most recent dose?

Pick the highest dose you were stable on (tolerating well for at least 2 weeks).

What was your most recent dose?

Pick the highest dose you were stable on (tolerating well for at least 2 weeks).

What was your most recent dose?

Pick the highest dose you were stable on (tolerating well for at least 2 weeks).

When did you last take it?

GI tolerance can reset after a gap, so this affects where we can safely start you.

Are you currently taking any medications?

Some medications may affect your eligibility

Please list your current medications

Include name, dosage, and frequency

Do you have any known drug allergies?

Please list your allergies

Are you pregnant, breastfeeding, or planning to become pregnant?

Do you have diabetes?

Type 1 diabetes is not eligible for GLP-1 therapy through our program.

Have you ever had an adverse or allergic reaction to Tirzepatide, Semaglutide, or Retatrutide?

Have you ever had an adverse or allergic reaction to any other GLP-1 medication?

Examples: Liraglutide (Saxenda), Dulaglutide (Trulicity), Exenatide (Byetta).

Do you currently consume alcohol?

How much alcohol do you consume?

Be honest — your doctor uses this to flag pancreatitis risk.

Anything else you'd like your doctor to know?

Share any additional information, questions, or concerns that may be helpful for your consultation.

This is optional - only include what you think is important

Upload a photo of the front of your government-issued ID.

Driver's license, state ID, or passport. Required for prescriber identity verification.

Upload a selfie holding your ID.

Hold your ID up next to your face so your prescriber can confirm the ID is yours.

Upload a full-body photo for your prescriber.

Stand in form-fitting clothing. This helps your provider confirm dosing. We never share this image outside your medical record.

Off-Label / Investigational Compound Consent

This therapy uses a compounded peptide that is not FDA-approved for any indication. It is prescribed off-label based on your doctor's clinical judgment. By proceeding, you acknowledge that you understand this is not an FDA-approved treatment, that long-term safety data may be limited, and that you consent to off-label prescribing. Your doctor will review this with you on your video visit.