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CHECK IF YOU
QUALIFY

Answer a few quick questions to see if medical weight loss may be right for you.
Takes about 2 minutes.

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Most patients do not need a live visit.
A provider reviews your answers and only schedules a visit if needed.

Check Eligibility

Birthday
Month
Day
Year
How tall are you? Feet
Inches
Are you pregnant, breastfeeding, or trying to get pregnant?
What approaches have you previously tried for weight loss? (Select all that apply)
Are you currently taking Semaglutide / Ozempic / Wegovy
No
Month 1 - 0.25mg
Month 2 - 0.50mg
Month 3 - 1.00mg
Month 4 - 1.50mg
Month 5 - 2.00mg
Month 6 - 2.50mg
Not sure
Are you currently taking Tirzepatide / Zepbound / Mounjaro
No
Month 1 - 2.50mg
Month 2 - 5.00mg
Month 3 - 7.50mg
Month 4 - 10.0mg
Month 5 - 12.50mg
Month 6 - 15.0mg
Not sure
Have you taken a GLP-1 in the past?
No
Yes
What has made weight loss hard for you?
Do any of these apply to you?
Do you take any of the following medications?
How would you working on your weight right now?
Actively managing
Some efforts
No active efforts
Do you have any medication allergies?
No
Yes
Have you had any surgeries?
No
Yes
Any questions for us?
No
Yes
I want
Semaglutide
Tirzepatide
I don't know

This form helps us determine if you may qualify for prescription weight loss treatment.

If eligible, you’ll receive a payment link to proceed.

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