form 1 – Vidamed

Not sure which medication to choose?

Answer these questions to find the right one for you.

Ready to Transform?

Let's start with your name and email to personalize your care and save your progress.

Email*

First name*

Last Name*

Reach your ideal weight without impossible diets.

What is your height and weight?

Height

Weight in lbs

Perfect! With a BMI of [X], we can continue.

We're in this together. Your goal is our goal.

What is your ideal weight?

Are you male or female? Male Female

Safety, first.

Do any of these apply to you?

Currently or possibly pregnant, or actively trying to become pregnant Breastfeeding or bottle-feeding with breastmilk Have given birth to a child within the last 6 months None of the above

Improving your life requires motivation.

What is your primary reason for looking into GLP-1 medication?

I want to live longer I want to feel and look better I want to reduce current health issues All of these

GLP-1s help you lose weight at a pace that works for you

How quickly are you hoping to reach your goal?

I'm fine taking it slow I'd like to see faster results I'm in no rush — steady is best

GLP-1 is safe, but these health conditions might prevent you from being prescribed.

Your answers are completely confidential and protected by HIPAA.

Do you have any of the following conditions? (select all that apply) High blood pressure High cholesterol Diabetes Heart disease Thyroid issues None of the above I'm not sure

A few more health questions

Do you have any of the following conditions? (select all that apply)

Kidney disease Liver disease Cancer Autoimmune disorder None of the above I'm not sure

Have you taken medication for weight loss within the past 4 weeks?* Yes, I've taken GLP-1 medication Yes, I've taken a different medication for weight loss No

Have you had prior weight loss surgeries? Yes No

If clinically appropriate, are you willing to: Reduce your caloric intake alongside medication Increase your physical activity alongside medication None of the above

Has your weight changed in the last year? Lost a significant amount Lost a little About the same Gained a little Gained a significant amount

If you have any known allergies, please list them here.

Which of these is most important to you? Lowest price Faster results Balanced option

Format preference I prefer to inject I prefer a tablet

Do you currently take any medications? Yes No

How motivated are you to reach [ideal weight]? I'm Ready! I'm feeling hopeful I'm cautious

Your responses will be reviewed by a doctor within two business days.

Do you have any further information which you would like our medical team to know? Yes No

Your consultation will be by text or email for convenience and speed.

If you have special circumstances, you can request a phone or video call with your doctor after completing this form.

In most cases, the info you've provided on this form will be enough for a doctor to make a decision.

What is your preferred language for communicating with our support team and medical doctors? English Spanish No preference

What is your date of birth?

Date of birth

Your Medical Review

BMI: [X] Current: [X] lbs Goal Weight: [X] lbs

Your transformation is closer than you think!

Let's proceed to check your eligibility.

What state will your medication be shipped to?

[NAME] how can you be reached if necessary?

Our medical team uses email and text for patient communication, as well as updates about programs and services.

Phone number