Step 1 of 22

4%
This field is hidden when viewing the form

Let's Get Started

Your Name(Required)
This field is hidden when viewing the form

LETS START WITH

The Basics

This information helps your healthcare provider determine if you’re eligible for treatment.

Sex Assigned at Birth(Required)
Date of Birth(Required)

Height & Weight

Have you seen your primary care provider in the past 12 months?(Required)
We want to make sure that there’s a healthcare provider outside of us overseeing your overall care.
Do you currently have, or have you ever been diagnosed with, any of the following heart or heart-related conditions?(Required)
Select all that apply
Do you currently have, or have you ever been diagnosed with, any of these hormone, kidney, or liver conditions?(Required)
Select all that apply
Do you currently have any of these conditions?(Required)
Do you currently have, or have a history of, any of these gastrointestinal conditions or procedures?(Required)
Select all that apply
Do you currently have, or have you ever been diagnosed with, any of these additional following conditions?(Required)
Select all that apply
“My weight is negatively impacting my quality of life.”(Required)
Please rate your agreement with this statement.
Because of my weight...(Required)
Select all of the statements that apply to you.
Do you have any allergies to prescription or over-the-counter medicines, herbs, vitamins, supplements, food, dyes etc?(Required)
Our Clinicians use this information in determining a safe and effective treatment.
Our Clinicians use this information in determining a safe and effective treatment.
Do you currently take any of the following medications?(Required)
Select all that apply
Include prescription and over-the-counter medications, herbs, minerals, inhalers, injections, and medication implants or patches.
Our Clinicians use this information in determining a safe and effective treatment.

BEFORE WE WRAP UP

Is there anything else you want your healthcare provider to know about your health?(Required)
Include any additional details about the conditions you’ve already reported.
This field is hidden when viewing the form
Which treatment option would you like to explore?(Required)
Select One
Which treatment option would you like to explore?(Required)
Select One
GLP-1 Medication Safety Disclosure(Required)
GLP-1 medications (such as semaglutide, tirzepatide and retatrutide) can help with weight loss, but they may cause side effects.

Common side effects: nausea, diarrhea, constipation, decreased appetite, headache, tiredness or hair loss.
Serious risks (less common): pancreatitis, gallbladder or kidney problems, low blood sugar, and in rare cases, thyroid tumors.

🚨 Do not use if you or a family member have had medullary thyroid cancer (MTC) or MEN-2.
Seek emergency help for severe stomach pain, persistent nausea, or allergic reaction (trouble breathing, swelling, rash).


This information does not replace medical advice. Our provider will discuss risks and benefits before prescribing.

Important Guidance While Taking Your GLP-1 Medication

To help you get the best results and feel your best while using your GLP-1 medication, please follow these key health habits:

1. Prioritize Protein Every Day
Your body needs protein to maintain muscle, support metabolism, and promote steady energy levels. Make sure to include a good source of protein (like eggs, chicken, fish, tofu, Greek yogurt or a protein shake) with every meal or snack.

2. Stay Well Hydrated
GLP-1 medications can sometimes reduce appetite and thirst. Even if you don’t feel thirsty, it’s important to drink enough water throughout the day — generally at least 64 ounces (8 cups) daily, or more if you’re active or in warm environments. Proper hydration supports digestion, prevents constipation, and helps your medication work more effectively.

3. Keep Moving — Exercise Is Essential
Regular physical activity helps preserve muscle, improves fat loss, and enhances your overall health while taking GLP-1s. Aim for at least 150 minutes of moderate activity each week (like brisk walking, cycling, or swimming), and include some resistance or strength training twice weekly if possible.

4. Listen to Your Body
If you feel weak, dizzy, or overly fatigued, you may not be getting enough nutrition or fluids. Adjust your protein and water intake and contact your healthcare provider if symptoms persist.

Retatrutide Patient Consent(Required)
This field is hidden when viewing the form
Semaglutide Vial(Required)
Semaglutide is the active ingredient used in Ozempic
Semaglutide – 0.5mg/mL of Vitamin B12(Required)
Semaglutide is the active ingredient used in Ozempic
This field is hidden when viewing the form
Semaglutide Pen(Required)
Semaglutide is the active ingredient used in Ozempic
This field is hidden when viewing the form
Semaglutide Prefilled Syringes(Required)
Semaglutide is the active ingredient used in Ozempic
This field is hidden when viewing the form
Semaglutide Daily Dissolvable Tablet - ThinneX(Required)
Semaglutide is the active ingredient used in Ozempic
This field is hidden when viewing the form
Tirzepatide + Glycine + B12 Vial(Required)
Tirzepatide is the active ingredient used in Mounjaro
Tirzepatide + B12 Vial(Required)
Tirzepatide is the active ingredient used in Mounjaro
This field is hidden when viewing the form
Tirzepatide Pen(Required)
Select One
This field is hidden when viewing the form
Tirzepatide +Glycine + B12 Prefilled Syringes(Required)
Select One
This field is hidden when viewing the form
Tirzepatide Dissolvable Tablet(Required)
Select One
Retatrutide + B12 Vial(Required)
Select One
Capsules(Required)
Select One
This field is hidden when viewing the form
Peptides
Click the Add Peptides button below to select a peptide and choose the quantity (maximum of 3 vials per peptide per customer). Repeat this to add additional peptides if you'd like.
Product Name Quantity Total Peptide Patient Consent Dosing Instructions Actions
         
There are no Peptides selected.

Maximum number of peptides selected reached.

Price: $0.00
Shipping Information(Required)
We will deliver medication right to your door.
Peptide Patient Consent(Required)
We have issued a CoverWell Agreement for the services you purchased today, which protects you in the event that you experience a complication. By signing this form, you're agreeing that you are giving up the right to sue this provider in exchange for strict liability and the rapid recovery of specified benefits through CoverWell. In addition, you provide your consent to be contacted by CoverWell by phone and email and waive the HIPAA Authorization Requirement from the service provider(s) by you, the patient. Your CoverWell Agreement will be issued to you via your chosen contact method, email or text. You are the sole recipient of the Agreement. Please save this information; this practice does not receive a copy of your CoverWell Agreement.

Payment Information

please wait
Credit Card(Required)
American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Expiration Date
 
  • -
  • Newsletter
Save with the 3-Month Supply?
Our providers usually recommend at least three months for optimal results, and it is more cost-effective long term. Would you like to continue with the 3-Month Supply?