Reach your goal weight without restrictive diets and exercise. Let's calculate your BMI to make sure you're a good candidate for medical weight loss. What is your height?
Perfect! With a BMI of , we can continue.
Based on your answers, it appears that you may not be a good fit for GLP-1 treatment at this time.
If you feel this is inaccurate, please review your answers and make any necessary corrections.
Gender
What are your weight loss goals? *
A licensed provider will review your health history and determine whether a compounded medication is appropriate for you. Available options and pricing are shown before you submit your application.
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What weight loss initiatives have you tried in the past? Select all that apply *
Are you currently taking any GLP-1 medications? *
Are you currently pregnant, breastfeeding, or planning to become pregnant within the next 2 months? *
Do you have any of the following conditions? Did you have any in the past? (Select any that apply.) *
Please check all current or past medical conditions. Select all that apply *
Do you have any allergies? (If none, just type “N/A.”) *
List any surgeries you have had in the past: If you haven't had any surgeries, type N/A *
Are you currently taking any medications, including prescriptions, over-the-counter meds, or supplements? If yes, please list them here! (The more details, the better!) *
Date of Birth
Which type of consultation do you prefer? (Let us know what works best for you!) *
Please review and attest to the following before continuing. Consent: I confirm that I am the patient completing this intake form and have reviewed all questions carefully. I attest that my answers are true, accurate, and complete to the best of my knowledge. I understand the importance of providing my doctor with complete and accurate health information for my care. *
Please confirm that all the information you've provided is true and complete. Consent: I confirm that I am the patient completing this intake form and have reviewed all questions carefully. I attest that my answers are true, accurate, and complete to the best of my knowledge. I understand the importance of providing my doctor with complete and accurate health information for my care. *
Injection and oral options may be available. A licensed provider will determine which treatment and format, if any, are appropriate for you.
Compounded semaglutide. A licensed provider will review whether this treatment is appropriate for you.
Compounded tirzepatide. A licensed provider will review whether this treatment is appropriate for you.
You'll choose format (injection or oral) and treatment duration in the next step.
Medical Disclaimer Compounded medications are not FDA-approved. The FDA does not review compounded drugs for safety, effectiveness, or quality.
Based on your intake form, you qualify for both medications. You can change your choice anytime. You can review available options below. A licensed provider will determine whether a treatment is appropriate for you.
Important:
Please upload a government-issued photo ID We use this only to verify your identity and protect your information. Foreign government IDs, such as a Mexican ID, are accepted. *
Drag & drop your file here or click to upload
