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See If You Are Eligible

Takes about 3-5 minutes

Complete this quick eligibility form to see if medical weight management support is appropriate. Please answer honestly..


No purchase required. This form is only to determine eligibility for next steps.


*Eligibility required. Not medical advice.

We’ll email you within 24–48 hours if you pre-qualify for next steps

Please use a real number, provider communication may be by text.

Which program are you interested in?
Coaching + Medical Support (Provider Review Required)
Medical Support Only (Provider Review Required)
Coaching Only
Not sure yet
Age range?
18-29
30-39
40-49
50-59
60+
Are you currently using a prescription weight management medication?
Yes
No
Have you ever been diagnosed with Bulimia (current or past)?
Yes
No
Have you ever been diagnosed with Anorexia Nervosa (current or past)?
Yes
No
Are you currently pregnant?
Yes
No
Are you currently planning a pregnancy?
Yes
No
Are you currently breastfeeding?
Yes
No
Do you or a family member have a history of Medullary Thyroid Cancer?
Yes
No
Have you been diagnosed with Multiple Endocrine Neoplasia (MEN)?
Yes
No
Do you have a personal history of gallbladder disease?
Yes
No
Have you had your gallbladder removed within the past 2 months?
Yes
No
Do you have a personal history of pancreatitis?
Yes
No
Have you had bariatric surgery within the past 12 months?
Yes
No
Do you currently use cocaine or methamphetamine?
Yes
No

*The following questions do not automatically disqualify you. They help our medical team determine safe and appropriate dosing

Do you have fasting triglycerides over 500?
Yes
No
Are you currently taking Warfarin (blood thinner)?
Yes
No
Are you currently taking Insulin?
Yes
No
Are you currently taking a prescription injection for diabetes or weight management? (Examples: Ozempic, Wegovy, Trulicity, Victoza)
Yes
No
I'm not sure
Are you currently taking Sulfonylureas (e.g., Glipizide, Glyburide)?
Yes
No
Is your current BMI below 25?
Yes
No
I don't know

Agreement

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