{"id":5443,"date":"2026-07-18T11:26:45","date_gmt":"2026-07-18T11:26:45","guid":{"rendered":"https:\/\/myvidamed.com\/landing-page\/"},"modified":"2026-07-24T06:49:03","modified_gmt":"2026-07-24T06:49:03","slug":"dm-intake-form","status":"publish","type":"page","link":"https:\/\/myvidamed.com\/en\/dm-intake-form\/","title":{"rendered":"Landing Page Intake Form"},"content":{"rendered":"<style>\r\nbody #glp-form .glp-select.error, body #glp-form .glp-select.input-error { border-color:#f02841 !important; }\r\n\r\n\r\n    .wrap_question_6 span.required,\r\n.wrap_question_8 span.required,\r\n.wrap_question_11 span.required {\r\n    display: none;\r\n}\r\n\r\n    .wrap_question_7 span.required,\r\n    .wrap_question_9 span.required,\r\n    .wrap_question_5 span.required,\r\n    #glp-form button.prev{\r\n        display:none;\r\n    }\r\n  button[type=\"submit\"]:disabled {\r\n    opacity: 0.6;\r\n    cursor: not-allowed;\r\n    pointer-events: none;\r\n}\r\nbutton[type=\"submit\"].loading {\r\n    opacity: 0.6;\r\n    cursor: not-allowed;\r\n    pointer-events: none;\r\n    position: relative;\r\n}\r\nbutton[type=\"submit\"].loading::after {\r\n    content: \"\";\r\n    display: inline-block;\r\n    width: 14px;\r\n    height: 14px;\r\n    margin-left: 8px;\r\n    border: 2px solid rgba(255,255,255,.4);\r\n    border-top-color: #fff;\r\n    border-radius: 50%;\r\n    animation: btn-spin .8s linear infinite;\r\n    vertical-align: middle;\r\n}\r\n\r\n@keyframes btn-spin {\r\n    to {\r\n        transform: rotate(360deg);\r\n    }\r\n}\r\n  .hidden {\r\n    display:none;\r\n  }\r\n  .bmi-box {\r\n    background: #fff;\r\n    font-size: 26px;\r\n    line-height: 34px;\r\n    text-align: center;\r\n    border: 2px solid #06b97a;\r\n    padding: 20px;\r\n    border-radius: 8px;\r\n    margin-top:20px;\r\n    margin-bottom:20px;\r\n    color:#575757;\r\n}\r\n  @media only screen and (max-width: 767px) {\r\n    .progress-label,#ast-scroll-top {\r\n        display: none !important;\r\n    }\r\n     .bmi-box { font-size:23px; }\r\n     .page-template-blank-tmpl .glp-step .question-title { font-size:25px; text-align:left; }\r\n     .page-template-blank-tmpl .glp-step .hero-desc { font-size:20px; line-height:26px; text-align:left; }\r\n}\r\n    #glp-landing-page .glp-step[data-step=\"1\"].active {\r\n        display: block !important;\r\n    }\r\n    .glp-option {\r\n    display: flex;\r\n    align-items: center;\r\n    gap: 12px;\r\n}\r\n\r\n.gender-icon {\r\n    width: 100px;\r\n    height: 100px;\r\n    object-fit: contain;\r\n}\r\n\r\n#glp-field-gender .glp-options {\r\n    display: flex;\r\n    flex-direction: row;\r\n    gap: 18px;\r\n    justify-content: space-between;\r\n}\r\n\r\n#glp-field-gender .glp-option {\r\n    flex: 1 1 0;\r\n    width: auto !important;\r\n    max-width: calc(50% - 9px);\r\n    display: flex;\r\n    align-items: center;\r\n    flex-direction:column;\r\n}\r\n#glp-field-gender .glp-option::before,\r\n.glp-treatment-card .glp-option::before {\r\n  display:none;\r\n}\r\n.glp-row .col-6{\r\n  width: 100%;\r\n}\r\n.glp-treatment-grid{\r\n    display:grid;\r\n    grid-template-columns:repeat(auto-fit,minmax(320px,1fr));\r\n    gap:30px;\r\n}\r\n\r\n.glp-treatment-card{\r\n    cursor:pointer;\r\n}\r\n\r\n.glp-treatment-card input{\r\n    display:none;\r\n}\r\n\r\n.glp-card-inner{\r\n    padding:35px;\r\n    text-align:center;\r\n    border:2px solid #e8ecf4;\r\n    border-radius:24px;\r\n    background:#fff;\r\n    transition:.3s;\r\n}\r\n\r\n.glp-treatment-card img{\r\n    width:100px;\r\n    margin:0 auto 20px;\r\n    display:block;\r\n}\r\n\r\n\r\n\r\n.glp-card-inner .type{\r\n    font-size:22px;\r\n    font-weight:700;\r\n    margin-bottom:10px;\r\n}\r\n\r\n.glp-card-inner p{\r\n    font-size:14px;\r\n    line-height:1.6;\r\n}\r\n\r\n.glp-card-inner .price{\r\n    margin:25px 0;\r\n    font-size:14px;\r\n}\r\n\r\n.glp-card-inner .price strong{\r\n    font-size:22px;\r\n    color:#000;\r\n}\r\n\r\n.glp-treatment-actions{\r\n    display:flex;\r\n    gap:12px;\r\n    margin-top:20px;\r\n}\r\n\r\n\r\n.glp-card-inner .title {\r\n    font-size: 24px;\r\n    color: #000;\r\n    margin-bottom: 10px;\r\n    display: block;\r\n}\r\n\r\n\/* Question 13 *\/\r\n \r\n#glp-form .glp-step .wrap_question_13 label.glp-option{\r\n    position: relative;\r\n  \r\n    padding: 18px 20px 18px 60px !important;\r\n}\r\n\r\n\/* Common icon *\/\r\n.wrap_question_13 .glp-option::before{\r\n    content: \"\";\r\n    position: absolute;\r\n    left: 20px;\r\n    top: 50%;\r\n    transform: translateY(-50%);\r\n    width: 24px;\r\n    height: 24px;\r\n    background-repeat: no-repeat;\r\n    background-size: contain;\r\n    background-position: center;\r\n}\r\n\r\n\/* Email *\/\r\n.wrap_question_13 .glp-option:nth-child(1)::before{\r\n    background-image: url('https:\/\/myvidamed.com\/wp-content\/plugins\/glp-form-plugin\/assets\/images\/email.svg');\r\n}\r\n\r\n\/* Video *\/\r\n.wrap_question_13 .glp-option:nth-child(2)::before{\r\n    background-image: url('https:\/\/myvidamed.com\/wp-content\/plugins\/glp-form-plugin\/assets\/images\/video.svg');\r\n}\r\n\r\n\/* Phone *\/\r\n.wrap_question_13 .glp-option:nth-child(3)::before{\r\n    background-image: url('https:\/\/myvidamed.com\/wp-content\/plugins\/glp-form-plugin\/assets\/images\/phone.svg');\r\n}\r\n\r\n\/* Hide radio button if needed *\/\r\n.wrap_question_13 .glp-option input[type=\"radio\"]{\r\n    display:none;\r\n}\r\n\r\n.glp-progress{\r\n    display:flex;\r\n    align-items:center;\r\n    width:100%;\r\n    gap:30px;\r\n}\r\n\r\n.progress-item{\r\n    display:flex;\r\n    align-items:center;\r\n    flex:1;\r\n}\r\n\r\n.progress-circle{\r\n    width:36px;\r\n    height:36px;\r\n    border:2px solid #c8c8c8;\r\n    border-radius:50%;\r\n    position:relative;\r\n    background:#fff;\r\n    flex-shrink:0;\r\n}\r\n\r\n.progress-circle:after{\r\n    content:\"\";\r\n    width:10px;\r\n    height:10px;\r\n    border-radius:50%;\r\n    background:transparent;\r\n    position:absolute;\r\n    left:50%;\r\n    top:50%;\r\n    transform:translate(-50%,-50%);\r\n}\r\n\r\n.progress-item.active .progress-circle,\r\n.progress-item.completed .progress-circle{\r\n    border-color:#58a8ff;\r\n}\r\n\r\n.progress-item.active .progress-circle:after{\r\n    background:#58a8ff;\r\n}\r\n\r\n.progress-item.completed .progress-circle{\r\n    background:#58a8ff;\r\n}\r\n\r\n.progress-item.completed .progress-circle:after{\r\n    content:\"\u2713\";\r\n    color:#fff;\r\n    background:none;\r\n    width:auto;\r\n    height:auto;\r\n    font-size:18px;\r\n    font-weight:700;\r\n}\r\n\r\n.progress-label{\r\n    margin:0 18px 0 12px;\r\n    white-space:nowrap;\r\n    font-size:18px;\r\n    color:#999;\r\n}\r\n\r\n.progress-item.active .progress-label,\r\n.progress-item.completed .progress-label{\r\n    color:#53c49c;\r\n}\r\n\r\n.progress-line{\r\n    flex:1;\r\n    height:2px;\r\n    background:#d9d9d9;\r\n}\r\n\r\n.progress-item.completed .progress-line{\r\n    background:#58a8ff;\r\n}\r\n\r\n.glp-image {\r\n    width: 100%;\r\n    text-align: center;\r\n}\r\n\r\n.glp-image img {\r\n    display: block;\r\n    max-width: 100%;\r\n    height: auto;\r\n    margin: 0 auto;\r\n}\r\n.page-template-blank-tmpl #glp-form .glp-select {\r\n    appearance: none !important;\r\n    -webkit-appearance: none !important;\r\n    -moz-appearance: none !important;\r\n    background-image: none !important;\r\n}\r\n.page-template-blank-tmpl #glp-form .glp-select {\r\n    border: 1px solid #dee2e6 !important;\r\n    border-radius: 6px !important;\r\n    padding: 8px 10px !important;\r\n    margin-bottom: 0 !important;\r\n    height: 45px;\r\n    background: #fff !important;\r\n    font-size: 16px !important;\r\n    font-weight: 500 !important;\r\n    background-image: url(\"data:image\/svg+xml,%3csvg xmlns='http:\/\/www.w3.org\/2000\/svg' viewBox='0 0 16 16'%3e%3cpath fill='none' stroke='%23343a40' stroke-linecap='round' stroke-linejoin='round' stroke-width='2' d='m2 5 6 6 6-6'\/%3e%3c\/svg%3e\") !important;\r\n    background-repeat: no-repeat !important;\r\n    background-size: 16px 12px !important;\r\n    background-position: right 15px center !important; \r\n    padding-right: 45px !important;\r\n}\r\n\r\n.page-template-blank-tmpl #glp-form input[type=\"text\"], .page-template-blank-tmpl .vm-ufield input[type=\"text\"], .page-template-blank-tmpl #glp-form input[type=\"email\"], .page-template-blank-tmpl .vm-ufield input[type=\"email\"], .page-template-blank-tmpl #glp-form input[type=\"tel\"], .page-template-blank-tmpl .vm-ufield input[type=\"tel\"], .page-template-blank-tmpl #glp-form input[type=\"number\"], .page-template-blank-tmpl .vm-ufield input[type=\"number\"], .page-template-blank-tmpl #glp-form input[name=\"name\"], .page-template-blank-tmpl .vm-ufield input[name=\"name\"], .page-template-blank-tmpl #glp-form input[name=\"phone\"], .page-template-blank-tmpl .vm-ufield input[name=\"phone\"], .page-template-blank-tmpl #glp-form input[name=\"zip\"], .page-template-blank-tmpl .vm-ufield input[name=\"zip\"], .page-template-blank-tmpl #glp-form textarea, .page-template-blank-tmpl .vm-ufield textarea, .page-template-blank-tmpl input[type=\"date\"], .page-template-blank-tmpl #glp-form select, .page-template-blank-tmpl .vm-ufield select {\r\n    border: 1px solid #dee2e6 !important;\r\n    border-radius: 6px !important;\r\n    padding: 8px 10px !important;\r\n    margin-bottom: 0 !important;\r\n    height: 45px;\r\n    background: #fff !important;\r\n    font-size: 16px !important;\r\n    font-weight: 500 !important;\r\n}\r\n\r\n.glp-progress { display:flex; align-items:center; width:100%; padding:20px 24px; background:#f5f2ed; box-sizing:border-box; max-width:1230px; margin:auto; background:transparent;margin-bottom:20px;  }\r\n.progress-item{display:flex;align-items:center;flex:1}\r\n.progress-item:last-child{flex:0 0 auto}\r\n.progress-circle{width:22px;height:22px;border:2px solid #c7c7c7;border-radius:50%;background:transparent;box-sizing:border-box;flex-shrink:0;display:inline-flex;align-items:center;justify-content:center}\r\n.progress-label{margin-left:10px;font-size:16px;color:#9b9b9b;white-space:nowrap}\r\n.progress-line{flex:1;height:1px;background:#c7c7c7;margin:0 16px}\r\n.progress-item.active .progress-circle{border-color:#53c49c}\r\n.progress-item.active .progress-circle::after{content:\"\";width:10px;height:10px;border-radius:50%;background:#53c49c}\r\n.progress-item.active .progress-label{color:#53c49c}\r\n.progress-item.completed .progress-circle{border-color:#53c49c;background:#53c49c}\r\n.progress-item.completed .progress-line{background:#53c49c}\r\n.progress-circle{transform:scale(1.6);margin-right:12px;}\r\n.glp-question{\r\n    margin:0;\r\n}\r\n\r\n.glp-step .hero-title{\r\n    display:block;\r\n    font-size:42px !important;\r\n    line-height:1.1 !important;\r\n    color:#1f2430;\r\n    margin-bottom:24px;\r\n    text-align:left;\r\n    \r\n    \r\n}\r\n\r\n.glp-step .hero-title .highlight {\r\n    color:#53c49c;\r\n     \r\n}\r\n\r\n.glp-step .hero-desc{\r\n    display:block;\r\n    font-size:22px;\r\n    line-height:1.6;\r\n    color:#666;\r\n    margin-bottom:20px;\r\n    font-weight:400;\r\n    text-align:left;\r\n}\r\n.page-template-blank-tmpl #glp-form > .glp-field > select { background:#fff !important; }\r\n.page-template-blank-tmpl .glp-step .mb-5 { margin-bottom:20px !important; }\r\n.glp-step .question-title {\r\n    display:block;\r\n    font-size:32px;\r\n    line-height:1.15;\r\n    font-weight:600;\r\n    color:#1f2430;\r\n    text-align:left;\r\n    \r\n}\r\n.custom-list-landing-form { padding-left:15px; }\r\n.custom-list-landing-form li { font-weight:400 !important; font-size:20px;  list-style-type: disc;  }\r\n.glp-progress-wrapper {\r\n    display: flex;\r\n    gap: 12px;\r\n    border-bottom: 1px solid #ccc;\r\n}\r\n\r\n.glp-back-btn {\r\n    width: 40px;\r\n    height: 40px;\r\n    border: none;\r\n    background: transparent;\r\n    display: flex;\r\n    align-items: center;\r\n    justify-content: center;\r\n    cursor: pointer;\r\n    color: #333;\r\n    font-size: 22px;\r\n    padding: 0;\r\n}\r\n\r\n.glp-back-btn:hover {\r\n    color: #000;\r\n}\r\n.trust-image-wrap {\r\n    text-align: center;\r\n    margin: 20px 0;\r\n}\r\n\r\n.trust-image {\r\n    width: 200px;\r\n    max-width: 100%;\r\n    height: auto;\r\n    display: inline-block;\r\n}\r\n\r\n.not-qualified-icon {\r\n    width: 60px;\r\n    height: 60px;\r\n    background-color: #06b97a; \r\n    color: #ffffff;\r\n    border-radius: 50%;\r\n    display: flex;\r\n    align-items: center;\r\n    justify-content: center;\r\n    font-size: 28px;\r\n    font-weight: bold;\r\n    line-height: 1;\r\n    margin-bottom: 12px;\r\n}\r\n\r\n.not-qualified-label {\r\n    color: #06b97a;\r\n    font-size: 19px;\r\n    font-weight: 500;\r\n    letter-spacing: 1px;\r\n    text-transform: uppercase;\r\n}\r\n.green-color.bold {\r\n    font-weight:inherit;\r\n}\r\nimg {\r\n    border-radius: 15px;\r\n}\r\n\r\n.green-color { color: #06b97a; }\r\n.page-template-blank-tmpl .glp-step label { font-size:19px !important; }\r\n.legitscript-image-wrap { width:80px; margin:20px auto; }\r\n.legitscript-image-wrap img { width:100%; height:100%;  }\r\n\/* .not-qualified{max-width:850px;margin:60px auto;padding:20px;text-align:center;font-family:Inter,Arial,sans-serif}\r\n.not-qualified-icon{width:90px;height:90px;margin:0 auto 20px;border-radius:50%;background:#53c49c;color:#fff;font-size:46px;font-weight:300;display:flex;align-items:center;justify-content:center;box-shadow:0 12px 35px #53c49c47}\r\n.not-qualified-label{display:block;text-transform:uppercase;letter-spacing:2px;font-size:15px;font-weight:700;color:#53c49c;margin-bottom:18px}\r\n.not-qualified h2{margin:0 auto 30px;max-width:760px;font-family:Georgia,serif;font-size:60px;line-height:1.15;font-weight:500;color:#1f2937}\r\n\r\n.not-qualified .bmi-box strong{color:#222;font-weight:700} *\/\r\n .not-qualified .description { font-size: 24px;\r\n    line-height: 32px; text-align:center; color:#575757; } \r\n.glp-bmi-value { color:#53c49c;font-weight:700;background:#fff;border-radius:100px}\r\n.review-text { margin-top:28px; color:#515050; font-size:20px; text-align:center; }\r\n.glp-step h2 {\r\n    font-size: 32px !important;\r\n}\r\n\r\nh1.mb-4.fw-normal {\r\n    font-size: 32px !important;\r\n    text-align: center;\r\n}\r\n.page-template-blank-tmpl .not-qualified h2 {margin:25px 0 20px;font-size:45px !important; line-height:47px !important;color:#222;font-weight:700}\r\n.page-template-blank-tmpl .not-qualified h2 span { margin-top:8px; color:#53c49c; font-weight:600; }\r\n.page-template-blank-tmpl .qualified-heading {margin: 10px 0 10px;\r\n    font-size: 45px !important;\r\n    line-height: 47px !important; color: #222 !important;\r\n    text-align: left !important;\r\n    margin-bottom: 20px !important;\r\n    font-weight: 600 !important;   }\r\n    .qualified-top .success {\r\n        color: #53c49c;\r\n    }\r\n.qualified-top .glp-bmi-value { background:transparent; color:#001c4c; }\r\n.page-template-blank-tmpl .qualified-top { margin:20px 0 20px; font-size:20px; line-height:1.2; font-weight:700; color:#222;   }\r\n.qualified-heading span { margin-top:10px;color:#53c49c; font-weight:600; }\r\n.glp-navigation{display:flex;justify-content:center;gap:16px}\r\n.page-template-blank-tmpl .glp-cc-form { margin-top:35px; }\r\n\r\n.page-template-blank-tmpl .glp-option:has(input:checked) {\r\n     box-shadow:none;\r\n}\r\n.page-template-blank-tmpl .glp-option::before {\r\n    display:none;\r\n}\r\n.page-template-blank-tmpl #glp-form .glp-step label.glp-option { padding:12px 18px !important; border:1px solid #ccc !important;  }\r\n.page-template-blank-tmpl #glp-form .glp-step label.glp-option:hover { border-color:#ccc !important; transform: translateY(0px);\r\n    box-shadow: none; }\r\n.page-template-blank-tmpl #glp-form .glp-step label.glp-option:has(input:checked) { border:2px solid #06b97a !important; background-color: #fdfaf5 !important;\r\n    font-weight: 500 !important; }\r\n.page-template-blank-tmpl .glp-option input[type=\"radio\"], .page-template-blank-tmpl .glp-option input[type=\"checkbox\"] {  appearance: none;\r\n    -webkit-appearance: none;\r\n    width: 16px !important;\r\n    display: block !important;\r\n    height: 16px;\r\n    border: 2px solid #bdbdbd !important;\r\n    border-radius: 50%;\r\n    background: #fff !important;\r\n    cursor: pointer;\r\n    position: relative;\r\n    margin: 0 !important;\r\n    opacity:1 !important;\r\n    flex-shrink: 0; }\r\n\r\n.page-template-blank-tmpl .glp-option input[type=\"radio\"]:checked,  .page-template-blank-tmpl .glp-option input[type=\"checkbox\"]:checked {\r\n    border: 2px solid #53c49c !important;\r\n    background: #53c49c !important;\r\n}\r\n.page-template-blank-tmpl .glp-question { font-size:35px !important;  text-align:left !important;  }\r\n.page-template-blank-tmpl #glp-form .glp-step #glp-field-gender label.glp-option {\r\n    border:2px solid #ccc !important; padding:25px 15px !important; font-size:24px !important; \r\n}\r\n.page-template-blank-tmpl #glp-field-gender .glp-option  input[type=\"radio\"], .page-template-blank-tmpl #glp-field-gender .glp-option input[type=\"checkbox\"] { display:none !important; }\r\n.page-template-blank-tmpl .glp-options { gap:10px; }\r\n.page-template-blank-tmpl #glp-form .glp-step #glp-field-gender label.glp-option:hover {\r\n    background-color: #f1f1f1 !important; border-color:#ccc !important; box-shadow:none !important; transform: translateY(-0px) !important;\r\n}\r\n.page-template-blank-tmpl #glp-form .glp-step #glp-field-gender label.glp-option:has(input:checked) {\r\n    border-color:#06b97a !important; \r\n}\r\n.hero-desc.subtitile-heading { font-size:17px; color:#1e293b; margin-top:15px;  }\r\n\r\n .page-template-blank-tmpl #glp-form .glp-step .wrap_question_9 label.glp-option,  .page-template-blank-tmpl #glp-form .glp-step .wrap_question_10 label.glp-option, .page-template-blank-tmpl #glp-form .glp-step label.glp-option.single-option, .page-template-blank-tmpl #glp-form .glp-step .wrap_question_6 label.glp-option { border: 0 !important;\r\n    background: transparent !important; padding: 2px 0 !important;\r\n    margin: 0 !important; }\r\n.page-template-blank-tmpl #glp-form .glp-step .wrap_question_9 label.glp-option:has(input:checked),  .page-template-blank-tmpl #glp-form .glp-step .wrap_question_10 label.glp-option:has(input:checked), .page-template-blank-tmpl #glp-form .glp-step label.glp-option.single-option:has(input:checked), .page-template-blank-tmpl #glp-form .glp-step .wrap_question_6 label.glp-option:has(input:checked)  {\r\n        border: 0 !important;\r\n    background: transparent !important;\r\n    }\r\n.page-template-blank-tmpl #glp-form .glp-step .wrap_question_9 label.glp-option input[type=\"checkbox\"],  .page-template-blank-tmpl #glp-form .glp-step .wrap_question_10 label.glp-option input[type=\"checkbox\"], .page-template-blank-tmpl #glp-form .glp-step label.glp-option.single-option input[type=\"checkbox\"],  .page-template-blank-tmpl #glp-form .glp-step .wrap_question_6 label.glp-option input[type=\"checkbox\"] {\r\n    width: 20px !important;\r\n    height: 20px;\r\n    border-radius: 6px;\r\n    background: #fff;\r\n    cursor: pointer;\r\n    margin: 0;\r\n    position: relative;\r\n    flex-shrink: 0;\r\n    transition: all .25s ease;\r\n}\r\n.page-template-blank-tmpl .custom-input .single-option input[type=\"checkbox\"]:checked::after { display:none !important; }\r\n.page-template-blank-tmpl .wrap_question_9 .glp-option input[type=\"checkbox\"]:checked,  .page-template-blank-tmpl .wrap_question_10 .glp-option input[type=\"checkbox\"]:checked, .page-template-blank-tmpl .glp-option.single-option input[type=\"checkbox\"]:checked, .page-template-blank-tmpl .wrap_question_6 .glp-option input[type=\"checkbox\"]:checked {\r\n    background-image: url(\"data:image\/svg+xml,%3Csvg xmlns='http:\/\/www.w3.org\/2000\/svg' viewBox='0 0 16 16'%3E%3Cpath fill='none' stroke='white' stroke-width='2.5' stroke-linecap='round' stroke-linejoin='round' d='M3.5 8.5l3 3 6-7'\/%3E%3C\/svg%3E\") !important;\r\n    background-repeat: no-repeat;\r\n    background-position: center;\r\n    background-size: 12px;\r\n}\r\n.logos-list{\r\n    display:flex;\r\n    justify-content:center;\r\n    align-items:center;\r\n    gap:30px;\r\n    list-style:none;\r\n    padding:0;\r\n    margin:0;\r\n}\r\n\r\n.logos-list li{\r\n    display:flex;\r\n    align-items:center;\r\n    justify-content:center;\r\n    height:70px; \r\n}\r\n\r\n.logos-list li img{\r\n    display:block;\r\n    max-height:45px;     \r\n    width:auto;\r\n    max-width:100%;\r\n    object-fit:contain;  \r\n    opacity:.45;      \r\n    transition:.3s;\r\n    filter:grayscale(100%);\r\n    overflow:inherit;\r\n}\r\n.page-template-blank-tmpl .consent-hide-q.custom-input .glp-question {\r\n    font-weight: 500 !important;\r\n    font-size: 20px !important;\r\n    line-height: 29px !important;\r\n}\r\n.graph-image { width:100%; max-width:546px; margin-left:auto; margin-right:auto; }\r\n\r\n.glp-top {\r\n    display: flex;\r\n    justify-content: space-between;\r\n    align-items: flex-start;\r\n}\r\n.glp-rating {\r\n    text-align: center;\r\n    margin-top: 0;\r\n    width:250px;\r\n}\r\n\r\n.stars {\r\n    color: #ffb900;\r\n    font-size: 35px;\r\n    line-height: 1;\r\n    letter-spacing: 2px;\r\n}\r\n\r\n.customers {\r\n    margin-top: 8px;\r\n    font-size: 23px;\r\n    line-height: 1.2;\r\n    font-weight: 500;\r\n    color:#000;\r\n}\r\n\/* -------------------------\r\n   INFO BOXES\r\n------------------------- *\/\r\n\r\n.glp-info-boxes {\r\n    display: flex;\r\n    justify-content: center;\r\n    align-items: stretch;\r\n    gap: 28px;\r\n    margin-top: 10px;\r\n}\r\n\r\n.glp-info-box {\r\n    min-width: 155px;\r\n    padding: 13px 24px;\r\n    box-sizing: border-box;\r\n    border: 2px solid #000;\r\n    border-radius: 11px;\r\n    display: flex;\r\n    flex-direction: column;\r\n    justify-content: center;\r\n    align-items: center;\r\n}\r\n\r\n.glp-info-box:nth-child(2) {\r\n    min-width: 228px;\r\n}\r\n\r\n.box-title {\r\n    font-size: 20px;\r\n    font-weight: 800;\r\n    letter-spacing: 2px;\r\n    margin-bottom: 7px;\r\n    color:#000;\r\n    font-weight:700;\r\n}\r\n\r\n.box-value {\r\n    font-size:29px;\r\n    line-height: 1;\r\n    font-weight: 500;\r\n    color:#000;\r\n}\r\n.highlight-title {\r\n    color: #001c4c !important;\r\n    font-size: 30px;\r\n    line-height: 60px;\r\n    font-weight: 700;\r\n    text-transform:uppercase;\r\n}\r\n.highlight-title span {\r\n    color: #53c49c;\r\n    font-style: italic;\r\n    text-decoration: underline;\r\n    text-decoration-thickness: 2px;\r\n    text-underline-offset: 5px;\r\n}\r\n.recommendation-top {\r\n    display: flex;\r\n    justify-content: space-between;\r\n    align-items: flex-start;\r\n}\r\n.recommendation-bottle {\r\n    width: 275px;\r\n    margin-left: 15px;\r\n    display: flex;\r\n    justify-content: center;\r\n}\r\n\r\n\r\n.recommendation-bottle img {\r\n    width: 100%;\r\n    height: auto;\r\n    display: block;\r\n}\r\n.recommendation-rating {\r\n    display: flex;\r\n    justify-content: center;\r\n    align-items: center;\r\n    margin: 10px auto 65px;\r\n}\r\n\r\n\r\n.recommendation-rating img {\r\n    width: 275px;\r\n    max-width: 100%;\r\n    height: auto;\r\n    display: block;\r\n}\r\nbody .glp-info-box {\r\n    margin:20px 0;\r\n}\r\n.recommendation-section{\r\n    margin-top:10px;\r\n}\r\n\r\n\/* =========================================\r\n   SUCCESS BOX\r\n========================================= *\/\r\n\r\n.success-box {\r\n    max-width: 875px;\r\n    min-height: 180px;\r\n    margin: 0 auto;\r\n    padding: 25px 35px;\r\n    box-sizing: border-box;\r\n    background: #c6bd8c;\r\n    border-radius: 22px;\r\n    display: flex;\r\n    align-items: center;\r\n    gap: 25px;\r\n    margin-top:50px;\r\n    margin-bottom:20px;\r\n}\r\n\r\n\r\n\/* =========================================\r\n   SMALL BOTTLE\r\n========================================= *\/\r\n\r\n.success-bottle {\r\n    width: 65px;\r\n    flex-shrink: 0;\r\n    display: flex;\r\n    justify-content: center;\r\n    align-items: center;\r\n}\r\n\r\n\r\n.success-bottle img {\r\n    width: 55px;\r\n    height: auto;\r\n    display: block;\r\n}\r\n\r\n\r\n\/* =========================================\r\n   SUCCESS TEXT\r\n========================================= *\/\r\n\r\n.success-text {\r\n    flex: 1;\r\n    font-size: 29px;\r\n    line-height: 1.35;\r\n    font-weight: 400;\r\n    color:#000;\r\n}\r\n\r\n\r\n.success-text strong {\r\n    color: #ffffff;\r\n    font-style: italic;\r\n    font-weight: 800;\r\n}\r\n\r\n\r\n\/* =========================================\r\n   PERCENTAGE\r\n========================================= *\/\r\n\r\n.success-percentage {\r\n    width: 180px;\r\n    flex-shrink: 0;\r\n    display: flex;\r\n    flex-direction: column;\r\n    align-items: center;\r\n    justify-content: center;\r\n}\r\n\r\n\r\n.success-percentage strong {\r\n    color: #ffffff;\r\n    font-size: 55px;\r\n    line-height: 1;\r\n    font-weight: 800;\r\n}\r\n\r\n\r\n.success-percentage span {\r\n    margin-top: 8px;\r\n    color: #ffffff;\r\n    font-size: 21px;\r\n    letter-spacing: 1px;\r\n}\r\n.glp-trustimg img { width:320px; }\r\n\r\n@media(max-width:1024px) {\r\n.glp-navigation button{font-size:22px;height:64px}\r\n.page-template-blank-tmpl .glp-question {  font-size: 32px !important; line-height:37px !important; }\r\n}\r\n@media(max-width:767px) {\r\n     .glp-top {\r\n        display: block;\r\n    }\r\n    .glp-rating {\r\n    margin-top: 10px;\r\n    width: auto;\r\n}\r\n.recommendation-top {\r\n        display: flex;\r\n        flex-direction: column;\r\n    }\r\n    .highlight-title {\r\n        font-size:42px; line-height: 1.1 !important;\r\n    }\r\n    .glp-info-boxes {\r\n        flex-wrap: wrap;\r\n        gap: 12px;\r\n    }\r\n\r\n    .glp-info-box {\r\n        min-width: 0;\r\n        flex: 1 1 calc(50% - 12px);\r\n        padding: 10px;\r\n        margin:10px 0;\r\n    }\r\n\r\n    .glp-info-box:nth-child(2) {\r\n        min-width: 0;\r\n        flex: 1 1 100%;\r\n    }\r\n        .success-box {\r\n        min-height: auto;\r\n\r\n        padding: 22px 18px;\r\n\r\n        border-radius: 18px;\r\n\r\n        display: flex;\r\n\r\n        flex-wrap: wrap;\r\n\r\n        gap: 12px;\r\n    }\r\n\r\n\r\n    \/* SMALL BOTTLE *\/\r\n\r\n    .success-bottle {\r\n        width: 45px;\r\n    }\r\n\r\n\r\n    .success-bottle img {\r\n        width: 42px;\r\n    }\r\n\r\n\r\n    \/* TEXT *\/\r\n\r\n    .success-text {\r\n        flex: 1;\r\n\r\n        font-size: 20px;\r\n\r\n        line-height: 1.35;\r\n    }\r\n\r\n\r\n    \/* PERCENTAGE *\/\r\n\r\n    .success-percentage {\r\n        width: 100%;\r\n\r\n        margin-top: 10px;\r\n\r\n        align-items: center;\r\n    }\r\n\r\n\r\n    .success-percentage strong {\r\n        font-size: 43px;\r\n    }\r\n\r\n\r\n    .success-percentage span {\r\n        font-size: 17px;\r\n\r\n        margin-top: 5px;\r\n    }\r\n\r\n.recommendation-bottle {\r\n        margin-left: auto;\r\n    margin-right: auto;\r\n    margin-bottom: 20px;\r\n        width: 200px;\r\n}\r\n.glp-navigation button { font-size:18px; height:58px; }\r\n.glp-navigation{flex-direction:column}\r\n.glp-navigation button{width:100%}\r\n.page-template-blank-tmpl .glp-question { font-size:26px !important; line-height:30px !important;  } \r\n.page-template-blank-tmpl #glp-form input, .page-template-blank-tmpl #glp-form textarea, .page-template-blank-tmpl #glp-form select { padding:0 !important; }\r\n.logos-list{\r\n        gap:10px;\r\n        flex-wrap:wrap;\r\n    }\r\n\r\n    .logos-list li{\r\n        flex:0 0 calc(33.333% - 14px); \r\n        height:50px;\r\n    }\r\n\r\n    .logos-list li img{\r\n        max-height:28px;\r\n    }\r\n}\r\n@media(max-width:480px){\r\n    #glp-field-gender .glp-options {\r\n        flex-direction:column;\r\n    }\r\n    #glp-field-gender .glp-options .glp-option { max-width: 100% !important; }\r\n    .page-template-blank-tmpl .glp-question { font-size:26px; !important; }\r\n}\r\n.not-qualified-custom{display:flex;flex-direction:column;align-items:center;margin-bottom:25px}\r\n.not-qualified-icon{width:90px;height:90px;border-radius:50%;background:#ef4444;display:flex;align-items:center;justify-content:center;margin-bottom:18px;box-shadow:0 12px 30px #ef444440}\r\n.not-qualified-icon svg{width:36px;height:36px}\r\n.not-qualified-label{display:inline-block;background:#ffe8e8;color:#ef4444;padding:8px 18px;border-radius:50px;font-size:14px;font-weight:700;letter-spacing:.5px;text-transform:uppercase}\r\n\r\n.review-text{font-size:17px;line-height:1.8;color:#666;margin:20px 0}\r\n\r\n.bmi-box strong{color:#53c49c;font-size:24px;font-weight:700}\r\n.glp-navigation{display:flex;justify-content:center;margin-top:35px}\r\n.glp-navigation .prev{background:#53c49c;color:#fff;border:none;border-radius:50px;padding:16px 36px;font-size:16px;font-weight:600;cursor:pointer;transition:.3s ease;box-shadow:0 12px 30px #53c49c59}\r\n.glp-navigation .prev:hover{background:#43b58e;transform:translateY(-2px)}\r\n\r\n\r\n\/*.glp-question-block {\r\n    max-width: 500px;\r\n    margin: auto;\r\n}\r\n*\/\r\n\r\n<\/style>\r\n<div class=\"glp-progress-wrapper\">\r\n    <div class=\"glp-progress\">\r\n        \r\n    <button type=\"button\" class=\"glp-back-btn\" id=\"glp-back-btn\" aria-label=\"Back\">\r\n        <svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"28\" height=\"28\" viewBox=\"0 0 28 24\" fill=\"none\">\r\n            <path d=\"M24 12H5\" stroke=\"#1E293B\" stroke-width=\"2\" stroke-linecap=\"round\"\/>\r\n            <path d=\"M10 7L5 12L10 17\" stroke=\"#1E293B\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/>\r\n        <\/svg>\r\n    <\/button>\r\n\r\n    <div class=\"progress-item active\">\r\n        <span class=\"progress-circle\"><\/span>\r\n        <span class=\"progress-label\">Start<\/span>\r\n        <span class=\"progress-line\"><\/span>\r\n    <\/div>\r\n\r\n    <div class=\"progress-item\">\r\n        <span class=\"progress-circle\"><\/span>\r\n        <span class=\"progress-label\">Details<\/span>\r\n        <span class=\"progress-line\"><\/span>\r\n    <\/div>\r\n\r\n    <div class=\"progress-item\">\r\n        <span class=\"progress-circle\"><\/span>\r\n        <span class=\"progress-label\">Eligibility<\/span>\r\n    <\/div>\r\n\r\n<\/div>\r\n\r\n<\/div>\r\n<div id=\"glp-form\">\r\n<form id=\"glp-landing-page\" class=\"glp-form glp-cc-form\" method=\"post\" enctype=\"multipart\/form-data\" novalidate>\r\n    <input type=\"hidden\" name=\"action\" value=\"save_landing_page_glp_form\" \/> \r\n<input type=\"hidden\" name=\"stripe-email-field\" class=\"stripe-email-field input\" \/>\r\n<input type=\"hidden\" name=\"form-type\" value=\"landing-page\"\/>\r\n\r\n<div class=\"glp-step active\" data-skip=\"true\" data-step=\"0\">\r\n\r\n\r\n\r\n\r\n  <div class=\"glp-question-block\">\r\n\r\n        <div class=\"glp-image\">\r\n            <img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/plugins\/glp-form-plugin\/assets\/images\/step1.jpg\"\r\n                        alt=\"GLP\">\r\n        <\/div>\r\n\r\n        <p class=\"glp-question mb-5\">\r\n\r\n            <span class=\"hero-title\">\r\n                Reach your goal weight                <span class=\"highlight\">\r\n                    without restrictive diets and exercise.                <\/span>\r\n            <\/span>\r\n\r\n            <span class=\"hero-desc\">\r\n                Let's calculate your BMI to make sure you're a good candidate for medical weight loss.            <\/span>\r\n\r\n            <span class=\"question-title\">\r\n                What is your height?            <\/span>\r\n\r\n\r\n\r\n        <\/p>\r\n\r\n    \r\n    <div class=\"glp-row\">\r\n\r\n      <!-- Height FT -->\r\n      <div class=\"glp-field\">\r\n        <label>Feet<\/label>\r\n            <select name=\"height_ft\" class=\"glp-select\" required>\r\n                <option value=\"\">Select feet<\/option>\r\n                                    <option value=\"4\">4<\/option>\r\n                                    <option value=\"5\">5<\/option>\r\n                                    <option value=\"6\">6<\/option>\r\n                            <\/select>\r\n\r\n        <!-- <small class=\"glp-help-text\">Please enter a number greater than or equal to 1<\/small> -->\r\n        <small class=\"glp-error-text\" data-error=\"height_ft\"><\/small>\r\n      <\/div>\r\n\r\n      <!-- Height IN -->\r\n      <div class=\"glp-field\">\r\n        <label>Inches<\/label>\r\n        <select name=\"height_in\" class=\"glp-select\" required>\r\n                    <option value=\"0\">0<\/option>\r\n                    <option value=\"1\">1<\/option>\r\n                    <option value=\"2\">2<\/option>\r\n                    <option value=\"3\">3<\/option>\r\n                    <option value=\"4\">4<\/option>\r\n                    <option value=\"5\">5<\/option>\r\n                    <option value=\"6\">6<\/option>\r\n                    <option value=\"7\">7<\/option>\r\n                    <option value=\"8\">8<\/option>\r\n                    <option value=\"9\">9<\/option>\r\n                    <option value=\"10\">10<\/option>\r\n                    <option value=\"11\">11<\/option>\r\n            <\/select>\r\n        <!-- <small class=\"glp-help-text\">Please enter a number from 0 to 11<\/small> -->\r\n        <small class=\"glp-error-text\" data-error=\"height_in\"><\/small>\r\n      <\/div>\r\n\r\n    <\/div>\r\n\r\n    <!-- Weight -->\r\n    <div class=\"glp-field\">\r\n      <label>Weight (lbs)<\/label>\r\n      <input type=\"number\" name=\"weight\" id=\"weight\" min=\"50\" max=\"700\" required>\r\n      <small class=\"glp-error-text\" data-error=\"weight\"><\/small>\r\n    <\/div>\r\n\r\n    <!-- BMI -->\r\n    <div class=\"glp-field hidden\">\r\n      <label>BMI<\/label>\r\n      <input type=\"hidden\" name=\"bmi\" id=\"bmi\" readonly>\r\n    <\/div>\r\n\r\n\r\n  <\/div>\r\n\r\n  <div class=\"glp-navigation\">\r\n    <button type=\"button\" class=\"next\">Continue<\/button>\r\n  <\/div>\r\n\r\n  <div class=\"trust-image-wrap\">\r\n    <img decoding=\"async\" class=\"trust-image\"\r\n        src=\"https:\/\/myvidamed.com\/wp-content\/plugins\/glp-form-plugin\/assets\/images\/trust.png?wuruewyu\"\r\n        alt=\"Trusted\">\r\n  <\/div>\r\n <div class=\"legitscript-image-wrap\">\r\n    <img decoding=\"async\" class=\"legitscript-image\"\r\n        src=\"https:\/\/myvidamed.com\/wp-content\/plugins\/glp-form-plugin\/assets\/images\/legit-script.png?wuruewyu\"\r\n        alt=\"Legitscript\">\r\n  <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\">\r\n  <div class=\"qualified hidden\">\r\n\r\n    <p class=\"qualified-top\">\r\n        <span class=\"success\">Perfect!<\/span>\r\n        With a BMI of        <strong><span class=\"glp-bmi-value\" id=\"glp-bmi-value\"><\/span><\/strong>,\r\n        we can continue.    <\/p>\r\n\r\n    <h2 class=\"qualified-heading\">\r\n        We're in this together.        <span>Your goal is our goal.<\/span>\r\n    <\/h2>\r\n\r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n        <button type=\"button\" class=\"next\">Continue<\/button>\r\n    <\/div>\r\n\r\n<\/div>\r\n\r\n\r\n<div class=\"not-qualified hidden\">\r\n    <div class=\"not-qualified-custom\">\r\n        <div class=\"not-qualified-icon\">\r\n            <svg width=\"37\" height=\"37\" viewBox=\"0 0 24 24\" fill=\"none\" stroke=\"white\" stroke-width=\"2\" stroke-linecap=\"round\">\r\n                <line x1=\"6\" y1=\"6\" x2=\"18\" y2=\"18\"\/>\r\n                <line x1=\"18\" y1=\"6\" x2=\"6\" y2=\"18\"\/>\r\n            <\/svg>\r\n        <\/div>\r\n\r\n        <span class=\"not-qualified-label\">\r\n            NOT ELIGIBLE        <\/span>\r\n    <\/div>\r\n    <h2>\r\n        It looks like you may not qualify        <span class=\"green-color\">for treatment.<\/span>\r\n    <\/h2>\r\n\r\n    <p class=\"description\">\r\n        Based on your answers, it appears that you may not be a good fit for GLP-1 treatment at this time.    <\/p>\r\n\r\n    <div class=\"bmi-box\">\r\n        Your BMI is        <strong><span class=\"glp-bmi-value\" id=\"glp-bmi-value\"><\/span><\/strong>.\r\n        To qualify for GLP-1 medications your BMI needs to be 27 or higher.    <\/div>\r\n\r\n    <p class=\"review-text\">\r\n        If you feel this is inaccurate, please review your answers and make any necessary corrections.    <\/p>\r\n\r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">\r\n            \u2190 Review My Answers        <\/button>\r\n    <\/div>\r\n\r\n<\/div>\r\n\r\n        <\/div>\r\n\r\n<div class=\"glp-step\" data-step=\"0\">\r\n\r\n  <div class=\"glp-question-block\">\r\n\r\n\r\n            <p class=\"glp-question mb-5\"> Gender<\/p>\r\n\r\n\r\n    <!-- Gender -->\r\n    <div class=\"glp-field\" id=\"glp-field-gender\">\r\n      <div class=\"glp-options\">\r\n        <label class=\"glp-option\">\r\n          <input type=\"radio\" name=\"gender\" value=\"male\" required>\r\n                      <img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/plugins\/glp-form-plugin\/assets\/images\/person-standing.svg\"\r\n                 alt=\"Male\"\r\n                 class=\"gender-icon\">\r\n\r\n          Male        <\/label>\r\n        <label class=\"glp-option\">\r\n          <input type=\"radio\" name=\"gender\" value=\"female\">\r\n                      <img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/plugins\/glp-form-plugin\/assets\/images\/person-standing-dress.svg\"\r\n                 alt=\"Female\"\r\n                 class=\"gender-icon\">\r\n\r\n          Female        <\/label>\r\n      <\/div>\r\n      <small class=\"glp-error-text\" data-error=\"gender\"><\/small>\r\n    <\/div>\r\n\r\n\r\n\r\n  <\/div>\r\n\r\n  <div class=\"glp-navigation\">\r\n     <button type=\"button\" class=\"prev\">Back<\/button>\r\n    <button type=\"button\" class=\"next\">Continue<\/button>\r\n  <\/div>\r\n\r\n<\/div>\r\n\r\n<div class=\"glp-step\">\r\n\r\n    \n    <div class=\"glp-question-block  wrap_question_5\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        What are your weight loss goals?            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            \n                    <!-- Show Radio Buttons -->\n                   \n                    \n                    <!-- Show Radio Buttons -->\n                \n<div class=\"glp-options\">\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_5\"\n                value=\"Lose 1-20lbs for good\"\n                required            >\n                                    Lose 1-20lbs for good        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_5\"\n                value=\"Lose 21-50lbs for good\"\n                            >\n                                    Lose 21-50lbs for good        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_5\"\n                value=\"Lose over 50lbs for good\"\n                            >\n                                    Lose over 50lbs for good        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_5\"\n                value=\"Maintain my healthy weight\"\n                            >\n                                    Maintain my healthy weight        <\/label>\n    <\/div>\n\n\n                \n        \n    <\/div>\n\n      \r\n\r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n        <button type=\"button\" class=\"next\">Continue<\/button>\r\n    <\/div>\r\n\r\n<\/div>\r\n\r\n<div class=\"glp-step\">\r\n\r\n<h2 class=\"mb-4 fw-normal qualified-heading\">\r\n    It feels like magic, but it&#039;s    <span class=\"text-highlight green-color\">\r\n        <b>        metabolic science. <\/b>\r\n    <\/span>\r\n<\/h2>\r\n\r\n\r\n  <div class=\"glp-image graph-image\">\r\n                      <img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/plugins\/glp-form-plugin\/assets\/images\/weight.png\"\r\n                 alt=\"GLP\">\r\n<\/div>\r\n <h4 class=\"mb-4 subtitle-heading\">\r\n    On average, GLP-1 patients <strong>lost 18% of their body weight<\/strong>.<\/h4>\r\n\r\n<p class=\"hero-desc subtitile-heading\">\r\n    Compounded GLP-1 medications offer <strong>effective active ingredients<\/strong> \u2013 but at a fraction of the price (80% less) and are more consistently available.<\/p>\r\n\r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n        <button type=\"button\" class=\"next\">Continue<\/button>\r\n    <\/div>\r\n\r\n<p class=\"hero-desc subtitile-heading\" style=\"text-align:center; margin-bottom:0; margin-top:60px;\">We've been featured on<\/p>\r\n<ul class=\"logos-list\">\r\n    <li><img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/uploads\/2026\/07\/Forbes-1.png\" \/><\/li>\r\n    <li><img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/uploads\/2026\/07\/Yahoo-1.png\" \/><\/li>\r\n    <li><img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/uploads\/2026\/07\/TNYT-1.png\" \/><\/li>\r\n    <li><img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/uploads\/2026\/07\/WSJ-1.png\" \/><\/li>\r\n    <li><img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/uploads\/2026\/07\/NBC-News-1.png\" \/><\/li>\r\n    <li><img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/uploads\/2026\/07\/FOX-1.png\" \/><\/li>\r\n<\/ul>\r\n<\/div>\r\n\r\n<div class=\"glp-step\">\r\n<h2 class=\"mb-4 fw-normal glp-question\">\r\n    Nothing has worked like this. I am down <span class=\"green-color bold\">52lbs in 5 weeks.<\/span> I've never experienced anything like it. I have more <span class=\"green-color bold\">energy and confidence<\/span> than I've had in years!<\/h2>\r\n\r\n\r\n  <div class=\"glp-image\">\r\n                  <img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/plugins\/glp-form-plugin\/assets\/images\/Before_After 3.png\"\r\n                 alt=\"GLP\">\r\n<\/div>\r\n  \r\n<p class=\"hero-desc subtitile-heading\">\r\n    Elena <strong>dropped<\/strong> 52lbs and <i>upped<\/i> her confidence in <span class=\"green-color\">only 3 months!<\/span><\/p>\r\n\r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n        <button type=\"button\" class=\"next\">Continue<\/button>\r\n    <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\">\r\n<h2 class=\"mb-4 fw-normal qualified-heading\">\r\n    How will GLP-1    <span class=\"green-color bold\"> <i> work for you? <\/i> <\/span>\r\n<\/h2>\r\n\r\n<div class=\"glp-image graph-image\">\r\n    <img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/plugins\/glp-form-plugin\/assets\/images\/vidaease-of-weightloss.png\"\r\n         alt=\"GLP\">\r\n\r\n<\/div>\r\n  \r\n<h5 class=\" mb-4\">\r\n            <ul class=\"custom-list-landing-form\">\r\n    <li>\r\n        <strong>Week 1 - 4 :<\/strong> Your body gets acclimated to GLP-1 medication    <\/li>\r\n\r\n    <li>\r\n        <strong>Week 4 - 8 :<\/strong> Weight loss is increasing more and more    <\/li>\r\n\r\n    <li>\r\n        <strong>Week 9+ :<\/strong> Your body has become a <strong>burning machine<\/strong>    <\/li>\r\n<\/ul>\r\n        <\/h5>\r\n\r\n    <p class=\"hero-desc subtitile-heading\">\r\n    We identify the <span class=\"green-color\">root causes<\/span> of your metabolic issues, so you get a <strong>long-term solution,<\/strong> not just another quick fix.<\/p>\r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n        <button type=\"button\" class=\"next\">Continue<\/button>\r\n    <\/div>\r\n    <p class=\"hero-desc subtitile-heading\" style=\"text-align:center; margin-bottom:0; margin-top:60px;\"> We've been featured on <\/p>\r\n<ul class=\"logos-list\">\r\n        <li><img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/uploads\/2026\/07\/Forbes-1.png\" \/><\/li>\r\n        <li><img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/uploads\/2026\/07\/Yahoo-1.png\" \/><\/li>\r\n        <li><img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/uploads\/2026\/07\/TNYT-1.png\" \/><\/li>\r\n        <li><img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/uploads\/2026\/07\/WSJ-1.png\" \/><\/li>\r\n        <li><img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/uploads\/2026\/07\/NBC-News-1.png\" \/><\/li>\r\n        <li><img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/uploads\/2026\/07\/FOX-1.png\" \/><\/li>\r\n    <\/ul>\r\n<\/div>\r\n\r\n\r\n<div class=\"glp-step\">\r\n\r\n    \n    <div class=\"glp-question-block  wrap_question_6\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        What weight loss initiatives have you tried in the past? Select all that apply            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-options\">\n                \n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_6[]\"\n                            value=\"Exercise, Dieting\"\n                            required                        >\n                        Exercise, Dieting                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_6[]\"\n                            value=\"Weight-loss Supplements\"\n                            required                        >\n                        Weight-loss Supplements                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_6[]\"\n                            value=\"Intermittent Fasting\"\n                            required                        >\n                        Intermittent Fasting                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_6[]\"\n                            value=\"None of the Above\"\n                            required                        >\n                        None of the Above                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_6[]\"\n                            value=\"Other\"\n                            required                        >\n                        Other                    <\/label>\n                            <\/div>\n\n        \n    <\/div>\n\n      \r\n\r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n        <button type=\"button\" class=\"next\">Continue<\/button>\r\n    <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\">\r\n\r\n    \n    <div class=\"glp-question-block  wrap_question_7\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Are you currently taking any GLP-1 medications?            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            \n                    <!-- Show Radio Buttons -->\n                   \n                    \n                    <!-- Show Radio Buttons -->\n                \n<div class=\"glp-options\">\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_7\"\n                value=\"Yes\"\n                required            >\n                                    Yes        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_7\"\n                value=\"No\"\n                            >\n                                    No        <\/label>\n    <\/div>\n\n\n                \n        \n    <\/div>\n\n      \r\n\r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n        <button type=\"button\" class=\"next\">Continue<\/button>\r\n    <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\">\r\n\r\n    \n    <div class=\"glp-question-block  wrap_question_8\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Are you currently pregnant, breastfeeding, or planning to become pregnant within the next 2 months?            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            \n                    <!-- Show Radio Buttons -->\n                   \n                    \n                    <!-- Show Radio Buttons -->\n                \n<div class=\"glp-options\">\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_8\"\n                value=\"Yes\"\n                required            >\n                                    Yes        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_8\"\n                value=\"No\"\n                            >\n                                    No        <\/label>\n    <\/div>\n\n\n                \n        \n    <\/div>\n\n      \r\n\r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n        <button type=\"button\" class=\"next\">Continue<\/button>\r\n    <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\">\r\n\r\n    \n    <div class=\"glp-question-block  wrap_question_9\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Do you have any of the following conditions? Did you have any in the past? (Select any that apply.)            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-options\">\n                \n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_9[]\"\n                            value=\"Gastroparesis\"\n                            required                        >\n                        Gastroparesis                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_9[]\"\n                            value=\"Pancreatic Cancer\"\n                            required                        >\n                        Pancreatic Cancer                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_9[]\"\n                            value=\"Pancreatitis\"\n                            required                        >\n                        Pancreatitis                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_9[]\"\n                            value=\"Type 1 diabetes or diabetes requiring insulin\"\n                            required                        >\n                        Type 1 diabetes or diabetes requiring insulin                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_9[]\"\n                            value=\"Hypoglycemia\"\n                            required                        >\n                        Hypoglycemia                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_9[]\"\n                            value=\"Medullary Thyroid Cancer (MTC) or family history of MTC\"\n                            required                        >\n                        Medullary Thyroid Cancer (MTC) or family history of MTC                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_9[]\"\n                            value=\"Bipolar Disorder\"\n                            required                        >\n                        Bipolar Disorder                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_9[]\"\n                            value=\"Schizophrenia\"\n                            required                        >\n                        Schizophrenia                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_9[]\"\n                            value=\"Family or personal history of Multiple Endocrine Neoplasia (MEN-2) syndrome\"\n                            required                        >\n                        Family or personal history of Multiple Endocrine Neoplasia (MEN-2) syndrome                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_9[]\"\n                            value=\"Anorexia or Bulimia\"\n                            required                        >\n                        Anorexia or Bulimia                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_9[]\"\n                            value=\"Current symptomatic gallstones or active gallbladder disease\"\n                            required                        >\n                        Current symptomatic gallstones or active gallbladder disease                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_9[]\"\n                            value=\"Active Substance Abuse Disorder\"\n                            required                        >\n                        Active Substance Abuse Disorder                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_9[]\"\n                            value=\"None of the above\"\n                            required                        >\n                        None of the above                    <\/label>\n                            <\/div>\n\n        \n    <\/div>\n\n      \r\n\r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n        <button type=\"button\" class=\"next\">Continue<\/button>\r\n    <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\">\r\n\r\n    \n    <div class=\"glp-question-block  wrap_question_10\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Please check all current or past medical conditions. Select all that apply            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-options\">\n                \n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Hypertension (high blood pressure)\"\n                            required                        >\n                        Hypertension (high blood pressure)                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"High cholesterol\"\n                            required                        >\n                        High cholesterol                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Type 2 diabetes\"\n                            required                        >\n                        Type 2 diabetes                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Obstructive sleep apnea\"\n                            required                        >\n                        Obstructive sleep apnea                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Gout\"\n                            required                        >\n                        Gout                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Metabolic syndrome\"\n                            required                        >\n                        Metabolic syndrome                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Heart disease, stroke, or peripheral vascular disease\"\n                            required                        >\n                        Heart disease, stroke, or peripheral vascular disease                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Heart Failure\"\n                            required                        >\n                        Heart Failure                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Atrial fibrillation or flutter\"\n                            required                        >\n                        Atrial fibrillation or flutter                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Tachycardia or fast heart rate\"\n                            required                        >\n                        Tachycardia or fast heart rate                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Any ECG abnormality or heart rhythm abnormality\"\n                            required                        >\n                        Any ECG abnormality or heart rhythm abnormality                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Gallbladder removed\"\n                            required                        >\n                        Gallbladder removed                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Fatty Liver (MASLD or MASH)\"\n                            required                        >\n                        Fatty Liver (MASLD or MASH)                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Cirrhosis or end-stage liver disease\"\n                            required                        >\n                        Cirrhosis or end-stage liver disease                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Chronic Kidney Disease Stage 3 or greater\"\n                            required                        >\n                        Chronic Kidney Disease Stage 3 or greater                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Hypothyroidism, Hyperthyroidism, or Thyroid Issues\"\n                            required                        >\n                        Hypothyroidism, Hyperthyroidism, or Thyroid Issues                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"None of the Above\"\n                            required                        >\n                        None of the Above                    <\/label>\n                            <\/div>\n\n        \n    <\/div>\n\n      \r\n\r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n        <button type=\"button\" class=\"next\">Continue<\/button>\r\n    <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\">\r\n\r\n    \n    <div class=\"glp-question-block  wrap_question_11\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Do you have any allergies? (If none, just type \u201cN\/A.\u201d)            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-field\">\n                <input \n                    id =\"question_11\"\n                    type=\"text\"\n                    name=\"question_11\"\n                    class=\"glp-input\"\n                    value=\"N\/A\"\n                    required                >\n            <\/div>\n\n        \n    <\/div>\n\n      \r\n\r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n        <button type=\"button\" class=\"next\">Continue<\/button>\r\n    <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\">\r\n\r\n    \n    <div class=\"glp-question-block  wrap_question_12\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        List any surgeries you have had in the past: If you haven&#039;t had any surgeries, type N\/A            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-field\">\n                <input \n                    id =\"question_12\"\n                    type=\"text\"\n                    name=\"question_12\"\n                    class=\"glp-input\"\n                    value=\"N\/A\"\n                    required                >\n            <\/div>\n\n        \n    <\/div>\n\n      \r\n\r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n        <button type=\"button\" class=\"next\">Continue<\/button>\r\n    <\/div>\r\n\r\n<\/div>\r\n\r\n\r\n\r\n<div class=\"glp-step\" >\r\n\r\n  <div class=\"glp-image\">\r\n                  <img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/plugins\/glp-form-plugin\/assets\/images\/medications.jpg\"\r\n                 alt=\"GLP\">\r\n<\/div>\r\n\r\n    \n    <div class=\"glp-question-block  wrap_question_21\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        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!)            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-field\">\n                <input \n                    id =\"question_21\"\n                    type=\"text\"\n                    name=\"question_21\"\n                    class=\"glp-input\"\n                    value=\"N\/A\"\n                    required                >\n            <\/div>\n\n        \n    <\/div>\n\n    \r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n           <button type=\"button\" class=\"next\">Continue<\/button>\r\n  \r\n    <\/div>\r\n\r\n<\/div>\r\n\r\n<div class=\"glp-step\" data-step=\"0\">\r\n\r\n  <div class=\"glp-question-block\">\r\n\r\n            <p class=\"glp-question mb-5\"> Date of Birth<\/p>\r\n\r\n    <!-- DOB -->\r\n    <div class=\"glp-field\">\r\n    \r\n      <input type=\"text\" name=\"dob\" id=\"dob\" required>\r\n      <small class=\"glp-error-text\" data-error=\"dob\"><\/small>\r\n    <\/div>\r\n\r\n  <\/div>\r\n\r\n  <div class=\"glp-navigation\">\r\n     <button type=\"button\" class=\"prev\">Back<\/button>\r\n    <button type=\"button\" class=\"next\">Continue<\/button>\r\n  <\/div>\r\n\r\n<\/div>\r\n\r\n<div class=\"glp-step\">\r\n\r\n    \n    <div class=\"glp-question-block  wrap_question_13\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Which type of consultation do you prefer? (Let us know what works best for you!)            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            \n                    <!-- Show Radio Buttons -->\n                   \n                    \n                    <!-- Show Radio Buttons -->\n                \n<div class=\"glp-options\">\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_13\"\n                value=\"Email and Text Message (Fastest Option)\"\n                required            >\n                                    Email and Text Message (Fastest Option)        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_13\"\n                value=\"Video Call\"\n                            >\n                                    Video Call        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_13\"\n                value=\"Phone Call\"\n                            >\n                                    Phone Call        <\/label>\n    <\/div>\n\n\n                \n        \n    <\/div>\n\n      \r\n\r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n        <button type=\"button\" class=\"next\">Continue<\/button>\r\n    <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\" data-step=\"\">\r\n  <div class=\"glp-row\">\r\n  <div class=\"col-6 mb-3 relative\">\r\n    <label>First Name*<\/label>\r\n    <input name=\"name\" required autocomplete=\"first_name\">\r\n  <\/div>\r\n   <div class=\"col-6 mb-3 relative\">\r\n    <label>Last Name*<\/label>\r\n    <input type=\"text\" name=\"last_name\" required autocomplete=\"off\">\r\n  <\/div>\r\n\r\n  <div class=\"col-6 mb-3 relative\">\r\n    <label>Phone*<\/label>\r\n    <input name=\"phone\" required autocomplete=\"off\" class=\"us-phone\"\r\n       value=\"+1 (___) ___ - ____\" mask=\"+1 (___) ___ - ____\" placeholder=\"+1 (___) ___ - ____\" >\r\n  <\/div>\r\n\r\n  <div class=\"col-6 mb-3 relative\">\r\n    <label>Email*<\/label>\r\n    <input type=\"email\" name=\"email\" required autocomplete=\"email\">\r\n  <\/div>\r\n\r\n  <div class=\"col-6 mb-3 relative\">\r\n    <label>Zip Code*<\/label>\r\n    <input name=\"zip\" required autocomplete=\"postal-code\">\r\n  <\/div>\r\n<\/div>\r\n\r\n      <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n        <button type=\"button\" class=\"next\">Continue<\/button>\r\n    <\/div>\r\n<\/div>\r\n\r\n<div class=\"glp-step\" data-step=\"15\">\r\n\r\n\r\n\r\n  <div class=\"glp-question-block consent-hide-q custom-input\">\r\n\r\n    <p class=\"glp-question mb-5\">\r\n      Please review and attest to the following before continuing.      <br> <br>\r\n\r\n      <strong>Consent:<\/strong>\r\n      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.      <span class=\"required\">*<\/span>\r\n    <\/p>\r\n\r\n    \n    <div class=\"glp-question-block  wrap_question_17\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Please confirm that all the information you&#039;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.            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            \n                    <!-- Show Radio Buttons -->\n                   \n                    \n                    <!-- Show Radio Buttons -->\n                \n<div class=\"glp-options\">\n    \n        <label class=\"glp-option single-option\">\n            <input \n                type=\"checkbox\"\n                name=\"question_17[]\"\n                value=\"I agree and consent\"\n                required            >\n                                    I agree and consent        <\/label>\n    <\/div>\n\n\n                \n        \n    <\/div>\n\n    \r\n    <small class=\"glp-error-text\" data-error=\"consent\"><\/small>\r\n\r\n  <\/div>\r\n\r\n  <div class=\"glp-navigation\">\r\n    <button type=\"button\" class=\"prev\">Back<\/button>\r\n    <button type=\"button\" class=\"next\">Continue<\/button>\r\n  <\/div>\r\n\r\n<\/div>\r\n\r\n\r\n\r\n<div class=\"glp-step\" data-step=\"4\">\r\n\r\n<div class=\"glp-treatment-grid\">\r\n\r\n    <!-- Semaglutide -->\r\n    <label class=\"glp-treatment-card\">\r\n\r\n\r\n        <div class=\"glp-card-inner\">\r\n\r\n            <img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/uploads\/2026\/09\/semaglutide-tab.png\"\r\n                 alt=\"Compounded Semaglutide\">\r\n\r\n            <span class=\"title\">\r\n                Compounded Semaglutide               \r\n<\/span>\r\n\r\n\r\n\r\n            <p>\r\n                Weekly injectable or daily tablet. Reduces appetite and controls cravings naturally. Clinically studied for significant weight loss.<br>\r\n              \r\n            <\/p>\r\n\r\n            <p class=\"price\">\r\n                Starting at                <strong>$197\/Month<\/strong>\r\n                (3-month plan)            <\/p>\r\n\r\n<div class=\"glp-options\">\r\n\r\n    <label class=\"glp-option\">\r\n        <input type=\"radio\"\r\n               name=\"treatment\"\r\n               value=\"semaglutide_injection\"\r\n               checked>\r\n        <span>Injection<\/span>\r\n    <\/label>\r\n\r\n    <label class=\"glp-option\">\r\n        <input type=\"radio\"\r\n               name=\"treatment\"\r\n               value=\"semaglutide_oral\">\r\n        <span>Oral<\/span>\r\n    <\/label>\r\n\r\n<\/div>\r\n\r\n\r\n        <\/div>\r\n    <\/label>\r\n\r\n    <!-- Tirzepatide -->\r\n    <label class=\"glp-treatment-card\">\r\n\r\n\r\n        <div class=\"glp-card-inner\">\r\n\r\n            <img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/plugins\/glp-form-plugin\/assets\/images\/a3.png\"\r\n                 alt=\"Compounded Tirzepatide\">\r\n\r\n            <span class=\"title\">\r\n                Compounded Tirzepatide            <\/span>\r\n\r\n            <p>\r\n                Weekly injectable or daily tablet. Dual-action for powerful results. Clinically studied for notable weight loss.            <\/p>\r\n\r\n            <p class=\"price\">\r\n                Starting at                <strong>$297\/Month<\/strong>\r\n                (3-month plan)            <\/p>\r\n\r\n<div class=\"glp-options\">\r\n\r\n    <label class=\"glp-option\">\r\n        <input type=\"radio\"\r\n               name=\"treatment\"\r\n               value=\"tirzepatide_injection\">\r\n        <span>Injection<\/span>\r\n    <\/label>\r\n\r\n    <label class=\"glp-option\">\r\n        <input type=\"radio\"\r\n               name=\"treatment\"\r\n               value=\"tirzepatide_oral\">\r\n        <span>Oral<\/span>\r\n    <\/label>\r\n\r\n<\/div>\r\n\r\n\r\n        <\/div>\r\n    <\/label>\r\n\r\n<\/div>\r\n\r\n  <div class=\"glp-navigation\">\r\n    <button type=\"button\" class=\"prev\">Back<\/button>\r\n    <button type=\"button\" class=\"next\">Continue<\/button>\r\n  <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\" data-step=\"4\">\r\n\r\n\r\n<section class=\"glp-approval-section\">\r\n    <div class=\"glp-top\">\r\n        <h2 class=\"mb-4 fw-normal qualified-heading\">\r\n    <span class=\"js-customer-name\"><\/span>'s GLP-1 prescription plan <span class=\"green-color bold\">pre-approved!<\/span>\r\n<\/h2>\r\n\r\n        <div class=\"glp-rating\">\r\n            <div class=\"stars\">\u2605\u2605\u2605\u2605\u2605<\/div>\r\n            <!-- <div class=\"customers\">250k+ Customers<\/div> -->\r\n        <\/div>\r\n    <\/div>\r\n    <div class=\"glp-info-boxes\">\r\n       <div class=\"glp-info-box\">\r\n    <div class=\"box-title\">CURRENT WEIGHT<\/div>\r\n    <div class=\"box-value js-current-weight\"><\/div>\r\n<\/div>\r\n<div class=\"glp-info-box\">\r\n    <div class=\"box-title\">BMI<\/div>\r\n    <div class=\"box-value js-bmi\"><\/div>\r\n<\/div>\r\n        <div class=\"glp-info-box\">\r\n            <div class=\"box-title\">SEX<\/div>\r\n            <div class=\"box-value js-gender\"><\/div>\r\n        <\/div>\r\n    <\/div>\r\n    <div class=\"glp-description\">\r\n        <p class=\"qualified-top\" style=\"font-weight:400;\">\r\n            You&#039;ll get personalized care for your unique biology with <strong>prescribed medication<\/strong>, 1:1 physician guidance, and 24\/7 Vidamed support with our own dedicated nursing staff.        <\/p>\r\n\r\n        <p class=\"qualified-top\">\r\n            Your medication price never goes up \u2013 even when your dose increases!        <\/p>\r\n    <\/div>\r\n<\/section>\r\n\r\n<div class=\"recommendation-top\">\r\n        <div class=\"recommendation-content\">\r\n            <h2 class=\"mb-4 fw-normal qualified-heading\">Our Recommendation<\/h2>\r\n            <p class=\"qualified-top\" style=\"font-weight:400;\">\r\n                Based on your intake form, we recommend <span class=\"green-color js-recommended-med\">Tirzepatide Weekly Injections<\/span> for the best weight loss results! Just a simple injection once per week.            <\/p>\r\n            <p class=\"hero-desc\">\r\n                Note: you can choose whichever medication you prefer, regardless of our recommendation!            <\/p>\r\n        <\/div>\r\n        <div class=\"recommendation-bottle\">\r\n            <img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/plugins\/glp-form-plugin\/assets\/images\/a1.png\" alt=\"Tirzepatide medication\">\r\n        <\/div>\r\n    <\/div>\r\n    <br>\r\n    <br>\r\n\r\n <!-- <p class=\"glp-note mb-5\">\r\n    Note: All options include personalized compounded medication as prescribed by your doctor, all necessary supplies, ongoing medical support, and free nationwide shipping.  <\/p>  -->\r\n\r\n  <select name=\"plan\" id=\"plan\" class=\"glp-select\" required>\r\n    <option value=\"\">Select a Plan<\/option>\r\n\r\n    <option value=\"semaglutide_monthly\" data-treatment=\"semaglutide\">\r\n        Monthly Plan - $297\/month    <\/option>\r\n    <option value=\"semaglutide_3month\" data-treatment=\"semaglutide\">\r\n        3-Month Plan - $197\/month ($591 total). Save $300.    <\/option>\r\n\r\n    <option value=\"tirzepatide_monthly\" data-treatment=\"tirzepatide\">\r\n        Monthly Plan - $397\/month    <\/option>\r\n    <option value=\"tirzepatide_3month\" data-treatment=\"tirzepatide\">\r\n        3-Month Plan - $297\/month ($891 total). Save $300.    <\/option>\r\n<\/select>\r\n\r\n    <section class=\"recommendation-section\">\r\n    \r\n    <div class=\"trust-image-wrap glp-trustimg\">\r\n        <img decoding=\"async\" class=\"trust-image\" src=\"https:\/\/myvidamed.com\/wp-content\/plugins\/glp-form-plugin\/assets\/images\/trust.png?wuruewyu\" alt=\"Trusted\">\r\n    <\/div>\r\n    <div class=\"success-box\">\r\n        <div class=\"success-bottle\">\r\n            <img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/plugins\/glp-form-plugin\/assets\/images\/a1.png\" alt=\"Tirzepatide\">\r\n        <\/div>\r\n        <div class=\"success-text\">\r\n            You have a <strong>very high<\/strong> chance of<br>success with GLP-1 medications        <\/div>\r\n        <div class=\"success-percentage\">\r\n            <strong>94.6%<\/strong>\r\n            <span>VERY HIGH<\/span>\r\n        <\/div>\r\n    <\/div>\r\n<\/section>\r\n\r\n\r\n  <div class=\"glp-info-box\" style=\"color:#000;\">\r\n    <p>Important:<\/p>\r\n    <ul class=\"custom-list-landing-form\">\r\n      <li>You will only be charged if the doctor approves the medication. If you do not qualify, no charge will be made.<\/li>\r\n      <li>Vidamed does not auto-charge. Your card is securely stored in the portal so you don't have to re-enter it<\/li>\r\n      <li>For Monthly plans: you're charged the first month price. Subsequent months are charged at regular price only after your approval.<\/li>\r\n      <li>For 3-month plans: it's a single upfront payment of the total amount.<\/li>\r\n      <li>You will always receive text\/email reminders to approve future refills.<\/li>\r\n    <\/ul>\r\n  <\/div>\r\n\r\n  <div class=\"glp-navigation\">\r\n    <button type=\"button\" class=\"prev\">Back<\/button>\r\n    <button type=\"button\" class=\"next\">Continue<\/button>\r\n  <\/div>\r\n\r\n<\/div>\r\n\r\n<div class=\"glp-step\">\r\n\r\n  <div class=\"glp-image\">\r\n                      <img decoding=\"async\" src=\"https:\/\/myvidamed.com\/wp-content\/plugins\/glp-form-plugin\/assets\/images\/reviews.png?4873468\"\r\n                 alt=\"GLP\">\r\n<\/div>\r\n  \r\n\r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n        <button type=\"button\" class=\"next\">Continue<\/button>\r\n    <\/div>\r\n\r\n<\/div>\r\n\r\n<div class=\"glp-step\" data-step=\"16\">\r\n\r\n  <h2 class=\"mb-5\">Billing Information<\/h2>\r\n\r\n  <div class=\"glp-row\">\r\n\r\n    <div class=\"glp-field mb-3\">\r\n      <label>Address <span class=\"required\">*<\/span><\/label>\r\n      <input type=\"text\" name=\"street\" id=\"street\"\r\n        placeholder=\"House No, Building\" required>\r\n      <small class=\"glp-error-text\" data-error=\"street\"><\/small>\r\n    <\/div>\r\n\r\n    <div class=\"glp-field mb-3\">\r\n      <label>Street Address<\/label>\r\n      <input type=\"text\" name=\"street2\" id=\"street2\"\r\n        placeholder=\"Street name\">\r\n    <\/div>\r\n\r\n  <\/div>\r\n\r\n  <div class=\"glp-row\">\r\n\r\n    <div class=\"glp-field mb-3\">\r\n      <label>City <span class=\"required\">*<\/span><\/label>\r\n      <input type=\"text\" name=\"city\" id=\"city\" required>\r\n      <small class=\"glp-error-text\" data-error=\"city\"><\/small>\r\n    <\/div>\r\n\r\n    <div class=\"glp-field mb-3\">\r\n      <label for=\"state\">State \/ Province <span class=\"required\">*<\/span><\/label>\r\n      <select name=\"state\" id=\"state\" required class=\"glp-select\">\r\n        <option value=\"\">Select State<\/option>\r\n        <option value=\"AL\">Alabama<\/option><option value=\"AK\">Alaska<\/option>\r\n        <option value=\"AZ\">Arizona<\/option><option value=\"AR\">Arkansas<\/option>\r\n        <option value=\"CA\">California<\/option><option value=\"CO\">Colorado<\/option>\r\n        <option value=\"CT\">Connecticut<\/option><option value=\"DE\">Delaware<\/option>\r\n        <option value=\"FL\">Florida<\/option><option value=\"GA\">Georgia<\/option>\r\n        <option value=\"HI\">Hawaii<\/option><option value=\"ID\">Idaho<\/option>\r\n        <option value=\"IL\">Illinois<\/option><option value=\"IN\">Indiana<\/option>\r\n        <option value=\"IA\">Iowa<\/option><option value=\"KS\">Kansas<\/option>\r\n        <option value=\"KY\">Kentucky<\/option><option value=\"LA\">Louisiana<\/option>\r\n        <option value=\"ME\">Maine<\/option><option value=\"MD\">Maryland<\/option>\r\n        <option value=\"MA\">Massachusetts<\/option><option value=\"MI\">Michigan<\/option>\r\n        <option value=\"MN\">Minnesota<\/option><option value=\"MS\">Mississippi<\/option>\r\n        <option value=\"MO\">Missouri<\/option><option value=\"MT\">Montana<\/option>\r\n        <option value=\"NE\">Nebraska<\/option><option value=\"NV\">Nevada<\/option>\r\n        <option value=\"NH\">New Hampshire<\/option><option value=\"NJ\">New Jersey<\/option>\r\n        <option value=\"NM\">New Mexico<\/option><option value=\"NY\">New York<\/option>\r\n        <option value=\"NC\">North Carolina<\/option><option value=\"ND\">North Dakota<\/option>\r\n        <option value=\"OH\">Ohio<\/option><option value=\"OK\">Oklahoma<\/option>\r\n        <option value=\"OR\">Oregon<\/option><option value=\"PA\">Pennsylvania<\/option>\r\n        <option value=\"RI\">Rhode Island<\/option><option value=\"SC\">South Carolina<\/option>\r\n        <option value=\"SD\">South Dakota<\/option><option value=\"TN\">Tennessee<\/option>\r\n        <option value=\"TX\">Texas<\/option><option value=\"UT\">Utah<\/option>\r\n        <option value=\"VT\">Vermont<\/option><option value=\"VA\">Virginia<\/option>\r\n        <option value=\"WA\">Washington<\/option><option value=\"WV\">West Virginia<\/option>\r\n        <option value=\"WI\">Wisconsin<\/option><option value=\"WY\">Wyoming<\/option>\r\n      <\/select>\r\n      <small class=\"glp-error-text\" data-error=\"state\"><\/small>\r\n    <\/div>\r\n\r\n  <\/div>\r\n\r\n  <div class=\"glp-row\">\r\n\r\n    <div class=\"glp-field mb-3\">\r\n      <label>ZIP \/ Postal Code <span class=\"required\">*<\/span><\/label>\r\n      <input type=\"text\" name=\"zip\" id=\"zip\" required>\r\n      <small class=\"glp-error-text\" data-error=\"zip\"><\/small>\r\n    <\/div>\r\n\r\n    <div class=\"glp-field mb-3\">\r\n      <label>Country<\/label>\r\n      <select name=\"country\" id=\"country\" class=\"glp-select\">\r\n        <option value=\"US\">United States<\/option>\r\n      <\/select>\r\n    <\/div>\r\n\r\n  <\/div>\r\n\r\n  <div class=\"glp-navigation\">\r\n    <button type=\"button\" class=\"prev\">Back<\/button>\r\n    <button type=\"button\" class=\"next\">Continue<\/button>\r\n  <\/div>\r\n\r\n<\/div>\r\n\r\n<div class=\"glp-step stripe-page step-end\" data-step=\"17\">\r\n\r\n  <div class=\"glp-question-block\">\r\n\r\n\r\n    <div class=\"glp-field mb-3\">\r\n      <label>Payment <span class=\"required\">*<\/span><\/label>\r\n      <div id=\"card-element\" class=\"glp-stripe-card\"><\/div>\r\n      <div id=\"card-errors\" class=\"glp-error-text\"><\/div>\r\n      <div id=\"stripeFields\"><\/div>\r\n      <div id=\"stripeErrors\"><\/div>\r\n      <div class=\"stripe-setup-id\">\r\n        <input type=\"hidden\" name=\"stripe-setup-id\" id=\"stripe-setup-id\" class=\"stripe-setup-id input\" \/>\r\n      <\/div>\r\n    <\/div>\r\n\r\n  <\/div>\r\n\r\n  <div class=\"glp-navigation\">\r\n    <button type=\"button\" class=\"prev\">Back<\/button>\r\n    <button type=\"button\" class=\"next next-payment\">Continue<\/button>\r\n  <\/div>\r\n\r\n<\/div>\r\n\r\n\r\n<div class=\"glp-step\" >\r\n\r\n    \n    <div class=\"glp-question-block  wrap_question_20\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        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.            <span class=\"required\">*<\/span>        <\/p>\n\n                    <div class=\"glp-text sub-heading\">\n                You may upload any government-issued photo ID, including a driver's \n                license, passport, state ID, or foreign government-issued ID, such as a Mexican ID.<\/div>\n            <div class=\"glp-field care-glp-upload-box\">\n\n    <label class=\"glp-upload-box\">\n\n        <input \n            type=\"file\"\n            name=\"question_20\"\n            accept=\"image\/*,.pdf\"\n            class=\"glp-input user_id_file\"\n            hidden\n            required        >\n\n        <div class=\"glp-upload-content\">\n            <p>Drag & drop your file here or click to upload<\/p>\n            <small>Accepted: JPG, PNG, PDF (Max 5MB)<\/small>\n        <\/div>\n\n    <\/label>\n\n    <div class=\"glp-file-preview\"><\/div>\n\n    <small class=\"glp-error-text\"><\/small>\n\n<\/div>\n\n\n        \n    <\/div>\n\n    \r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n        <button type=\"submit\" id=\"landing-submit-form\" class=\"glp-submit-btn\">Submit<\/button>\r\n    <\/div>\r\n\r\n<\/div>\r\n\r\n\r\n\r\n<\/form>\r\n<\/div> \r\n<div class=\"glp-after-response hidden hide\">\r\n\r\n    <!-- <h2>What Happens Next?<\/h2>\r\n\r\n    <div class=\"glp-r-step\">\r\n        <span class=\"step-label\">STEP 1<\/span>\r\n        <h3>Physician Review<\/h3>\r\n        <p>\r\n            You&#039;re already pre-qualified. After checkout, a licensed healthcare provider will review your information and begin the approval process.        <\/p>\r\n    <\/div>\r\n\r\n    <div class=\"glp-r-step\">\r\n        <span class=\"step-label\">STEP 2<\/span>\r\n        <h3>Fast Prescription Approval<\/h3>\r\n        <p>\r\n            Many reviews are completed quickly, and same-day consultations may be available when clinically appropriate.        <\/p>\r\n    <\/div>\r\n\r\n    <div class=\"glp-r-step\">\r\n        <span class=\"step-label\">STEP 3<\/span>\r\n        <h3>Medication Preparation &amp; Shipping<\/h3>\r\n        <p>\r\n            Once approved, your medication is prepared and shipped. You&#039;ll receive tracking info within 1\u20132 business days, and your prescription will be on its way.        <\/p>\r\n    <\/div>\r\n\r\n    <div class=\"glp-r-step\">\r\n        <span class=\"step-label\">STEP 4<\/span>\r\n        <h3>Easy Refills<\/h3>\r\n        <p>\r\n            When it&#039;s time for a medication refill, you&#039;ll simply fill out a simple online form in your Vidamed Patient Portal. We&#039;ll send email and text updates with tracking info when your next shipment heads your way!        <\/p>\r\n    <\/div>\r\n\r\n    <div class=\"glp-r-step\">\r\n        <span class=\"step-label\">STEP 5<\/span>\r\n        <h3>Unlimited Support<\/h3>\r\n        <p>\r\n            Have questions about your progress, side effects, or dosage? 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