General Info

First Name

Last Name

Date of birth

Height (feet)

Height (Inches)

Postal Code

Phone

Do any of the following apply to you?

None of the below

Severe kidney disease (on or about to be on dialysis)

Severe liver disease (including cirrhosis or any other severe liver disease)

Current or prior eating disorder

Current suicidal thoughts and/or prior suicidal attempt

Cancer (active diagnosis / treatment / <5 years remission)

History of organ transplant on anti-rejection medication

Severe gastrointestinal condition (gastroparesis, blockage, bowel resection, etc.)

Currently untreated / unmonitored opioid, alcohol, or substance use disorder

Personal or family history of medullary thyroid cancer or MEN2

Type 2 diabetes on insulin or A1c > 10%

Type 1 diabetes

Diabetic retinopathy / optic nerve damage / blindness

Use of blood thinner warfarin (Coumadin / Jantoven)

History of or current pancreatitis

Use of street drugs or prescription meds without valid prescription

Heart attack or stroke in the past 1 year

Sex at Birth

Male

Female

(Females only) Do any of the following apply to you?

None of the below

Currently or possibly pregnant, or actively trying to become pregnant

Breastfeeding or bottle-feeding with breastmilk

Have given birth to a child within the last 6 months

Please note that we strongly recommend that you use an effective method of contraception during treatment with a GLP-1 medication and for at least 2 months thereafter. For those taking Zepbound or Mounjaro (tirzepatide), we recommend switching to a non-oral contraceptive method or adding a barrier method of contraception for four weeks after initiation and for four weeks after each dose escalation.

Based on your answers, medical clearance is required before proceeding. Please review the next instructions to confirm your eligibility.

Do any of these health conditions or situations apply to you? Please note that any of these will require clearance from your primary care or other physician before we can prescribe medication.

None of the below

Inflammatory bowel disease (IBD) including Crohn’s disease or ulcerative colitis

Low sodium levels or a diagnosis of SIADH (syndrome of inappropriate antidiuretic hormone secretion)

Ongoing chronic use of opiate pain medications

Personal history of thyroid cancer (other than medullary thyroid carcinoma)

Personal or family history of medullary thyroid carcinoma (MTC) or MEN2

Based on your answers, medical clearance is required before proceeding. Please review the next instructions to confirm your eligibility.

Do any of these health conditions or situations apply to you?

Based on your responses, you are currently not eligible for Sermorelin treatment. Please consult your healthcare provider for guidance. Other treatment options may still be available.

Your responses indicate that a review by your healthcare provider is required before proceeding with certain treatments. Please wait for further instructions from our medical team

Based on your response, Ondansetron is not safe for you. Please consult your healthcare provider after selecting this field.

Has your gallbladder been surgically removed?

Yes

What is Your Current Height and Weight?

Height (inches)

Weight (pounds)

BMI score

Are you currently taking or have recently (within the last 1 month) taken medication(s) for weight loss?

Yes – GLP-1 medication (within last 1 month)

Yes – Non-GLP-1 medication (within last 1 month)

No – Took weight loss meds before, but over 1 month ago

No – Never taken weight loss medication

Please list the name, dose, frequency, and timeline of your weight loss medication(s).

Medication Name

Dose

Frequency

Timeline / Duration

Additional Notes (Optional)

What was your starting weight in pounds (lbs)?

What is your current weight in pounds (lbs)?

Do you agree to only obtain weight loss medication through this platform moving forward?

Yes

When was your last dose of medication? This question is required before further medication can be prescribed.

Please upload a picture of your current GLP-1 medication pen or vial

If your last dose of GLP-1 medication was greater than 4 weeks ago, please note that we restart the dose at level 1 (the lowest dose) of medication.

Do any of the following apply to your coronary artery disease?

None of the below

Active or frequent chest pain or shortness of breath

Hospitalization for heart disease in the past 1 year

Multiple dose or medication increases for heart disease in the past 1 year

Heart disease not managed by a physician such as a cardiologist or a primary care physician

Do any of the following apply to your congestive heart failure?

None of the below

Active or frequent chest pain or shortness of breath

Hospitalization for heart disease in the past 1 year

Multiple dose or medication increases for heart disease in the past 1 year

Heart disease not managed by a physician such as a cardiologist or a primary care physician

Please list your current prescription and over-the-counter medications, including name, dose, and frequency.

Please list your medication allergies, including name and reaction.

Have you had prior bariatric (weight loss) surgery?

Yes

Please list all prior bariatric (weight loss) surgeries. Include the type of surgery and date(s).

Which of the following lifestyle factors apply to you?

I have attempted to lose weight in a weight management program before, such as through caloric restriction, exercise, or behavior modification.

I am willing to reduce my caloric intake alongside medication, if clinically appropriate.

I am willing to increase my physical activity alongside medication, if clinically appropriate.

None of the above

Please provide brief details about your prior weight loss efforts.

What is your current or average resting heart rate range?

<60 beats per minute

60-100 beats per minute

101-110 beats per minute

>110 beats per minute

If you are eligible, we take your specific situation into account while determining your medication formulation. To help with this, please select all of the following formulation options that you are interested in.

May help maintain muscle mass

Does not require injections

May help manage side effects such as nausea/vomiting

May assist with aging and longevity (cellular/DNA damage, immune system dysfunction, etc)

May assist with improving cognitive function and mental clarity

May assist with maintaining energy levels

May assist with insulin resistance and hormonal status

May assist with improving sleep quality

I’m not sure - I’d like to discuss formulation options with a clinician via a live virtual consult

Which dosing approach would you like to start with for your medical weight loss journey?

Standard (most common) starting dose with ability to adjust - recommended for most patients

Lower than standard starting dose with ability to adjust - recommended for patients who have had side effects with GLP-1/GIP medications in the past

Lower than standard starting dose with ability to adjust - recommended for patients who only want to lose a small amount of weight

Is there any further information which you would like the clinician to know?