{"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\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  @media only screen and (max-width: 767px) {\r\n    .progress-label,#ast-scroll-top {\r\n        display: none !important;\r\n    }\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: 22px;\r\n     color:#000;\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:#58a8ff;\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\r\n.glp-progress{display:flex;align-items:center;width:100%;padding:20px 24px;background:#f5f2ed;box-sizing:border-box;max-width:1130px;margin:auto;background:transparent;margin-bottom:42px}\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:35px !important;\r\n    line-height:1.1 !important;\r\n    color:#1f2430;\r\n    margin-bottom:24px;\r\n}\r\n\r\n.glp-step .hero-title .highlight{\r\n    display:block;\r\n    color:#53c49c;\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:40px;\r\n}\r\n\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}\r\n.glp-progress-wrapper {\r\n    display: flex;\r\n    gap: 12px;\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    <\/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        <i class=\"eicon-arrow-left\" aria-hidden=\"true\"><\/i>\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  <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\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\r\n    <div class=\"not-qualified-icon\">\r\n        \u2715\r\n    <\/div>\r\n\r\n    <span class=\"not-qualified-label\">\r\n        NOT ELIGIBLE    <\/span>\r\n\r\n    <h2>\r\n        It looks like you may not qualify        <span>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\r\n\r\n\r\n    <!-- Gender -->\r\n    <div class=\"glp-field\" id=\"glp-field-gender\">\r\n      <label>Gender<\/label>\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<div class=\"glp-step\" data-step=\"0\">\r\n\r\n  <div class=\"glp-question-block\">\r\n\r\n\r\n\r\n    <!-- DOB -->\r\n    <div class=\"glp-field\">\r\n      <label>Date of Birth<\/label>\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<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?                    <\/p>\n\n        \n            \n                    <!-- Show Radio Buttons -->\n                   \n                    \n                    <!-- Show Radio Buttons -->\n                \n<div class=\"glp-options\">\n            <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_5\"\n                value=\"Lose 1-20lbs for good\"\n                            >\n                                    Lose 1-20lbs for good        <\/label>\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            <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            <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            <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_5\"\n                value=\"None of the above\"\n                            >\n                                    None of the above        <\/label>\n            <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_5\"\n                value=\"Other\"\n                            >\n                                    Other        <\/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<div class=\"mb-4 fw-normal\">\r\n    It feels like magic, but it&#039;s    <span class=\"text-highlight\">\r\n        metabolic science.    <\/span>\r\n<\/div>\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\/weight.png\"\r\n                 alt=\"GLP\">\r\n<\/div>\r\n <h5 class=\"mb-4\">\r\n    On average, GLP-1 patients <strong>lost 18% of their body weight<\/strong>.<\/h5>\r\n<p>\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<\/div>\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                        >\n                        Exercise, Dieting                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_6[]\"\n                            value=\"Weight-loss Supplements\"\n                        >\n                        Weight-loss Supplements                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_6[]\"\n                            value=\"Intermittent Fasting\"\n                        >\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                        >\n                        None of the Above                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_6[]\"\n                            value=\"Other\"\n                        >\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<h2 class=\"mb-4 fw-normal\">\r\n    \"Nothing has worked like this. I am down <span class=\"green\">25lbs in 5 weeks.<\/span> I've never experienced anything like it. I have more <span class=\"green\">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>\r\n    Elena <strong>dropped<\/strong> 52lbs and <i>upped<\/i> her confidence in <span class=\"brown\">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<h1 class=\"mb-4 fw-normal\">\r\n    How will GLP-1 work for you?<\/h1>\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\/vidaease-of-weightloss.png\"\r\n         alt=\"GLP\">\r\n\r\n<\/div>\r\n  \r\n<h5 class=\" mb-4\">\r\n            <ul>\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      <p>\r\n    We identify the <span class=\"brown\">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\r\n<\/div>\r\n\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            <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_7\"\n                value=\"Yes\"\n                required            >\n                                    Yes        <\/label>\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            <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_8\"\n                value=\"Yes\"\n                required            >\n                                    Yes        <\/label>\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                        >\n                        Gastroparesis                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_9[]\"\n                            value=\"Pancreatic Cancer\"\n                        >\n                        Pancreatic Cancer                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_9[]\"\n                            value=\"Pancreatitis\"\n                        >\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                        >\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                        >\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                        >\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                        >\n                        Bipolar Disorder                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_9[]\"\n                            value=\"Schizophrenia\"\n                        >\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                        >\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                        >\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                        >\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                        >\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                        >\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                        >\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                        >\n                        High cholesterol                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Type 2 diabetes\"\n                        >\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                        >\n                        Obstructive sleep apnea                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Gout\"\n                        >\n                        Gout                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Metabolic syndrome\"\n                        >\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                        >\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                        >\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                        >\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                        >\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                        >\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                        >\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                        >\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                        >\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                        >\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                        >\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                        >\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                    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                    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_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            <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            <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            <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\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=\"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>\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            <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\/plugins\/glp-form-plugin\/assets\/images\/semaglutide.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\/tirzepatide.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\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\">\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  \r\n  <div class=\"glp-info-box small-dot-list\">\r\n    <p>Important:<\/p>\r\n    <ul>\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\/review.jpg\"\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>\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\">\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=\"button\" class=\"next\">Continue<\/button>\r\n    <\/div>\r\n\r\n<\/div>\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                    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=\"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<\/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 Direct Meds 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? You&#039;ll have unlimited, 24\/7 access to our nursing team and licensed clinicians \u2014 whenever you need us.        <\/p>\r\n    <\/div>\r\n\r\n<\/div>\r\n\r\n<script>\r\n  jQuery(function($){\r\n\r\n  \r\nfunction updatePlanOptions() {\r\n    var treatment = $('input[name=\"treatment\"]:checked').val();\r\n  console.log(treatment);\r\n  var parts = treatment.split('_');\r\nvar medication = parts[0]; \/\/ semaglutide or tirzepatide\r\nvar type = parts[1];       \/\/ injection or oral\r\n\r\n    $('#plan option').hide();\r\n    $('#plan option:first').show(); \/\/ Select a Plan\r\n\r\n    $('#plan option[data-treatment=\"' + medication + '\"]').show();\r\n\r\n    $('#plan').val('');\r\n}\r\n\r\nupdatePlanOptions();\r\n\r\n$(document).on('change', 'input[name=\"treatment\"]', function () {\r\n    updatePlanOptions();\r\n});\r\n});\r\njQuery(function ($) {\r\n    $('.wrap_question_8 input[name=\"question_8\"][value=\"No\"]')\r\n        .prop('checked', true)\r\n        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class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"blank-tmpl.php","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center 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