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Your goals

Let's start with your goals

Tell us where you are today and where you want to be. This takes about 5 minutes, and everything stays private. Just have questions? Read the FAQ →

Your BMI
—
Enter weight & height
What is your weight-loss goal? *
Have you tried weight-loss injection medications before? *
What other weight-loss programs have you tried? *
If a GLP-1 is clinically appropriate, are you willing to: *
Allergies & medications

What you're taking now

This helps our pharmacist screen for interactions before recommending anything.

Allergies
Current medications
Family & surgical history

Your background

Family and surgical history give important context for safe treatment.

Family health history
This is important for GLP-1 safety. A clinician will review it closely with you — it doesn't automatically disqualify you, but it does require careful evaluation.
Surgical history
Medical history

Have you had any of these?

Tap Y or N for each — or check "None" to mark them all No. Anything flagged is reviewed by a clinician, not an algorithm.

Lifestyle

A bit about your daily life

These lifestyle factors help us personalize your protocol.

Do you currently consume alcohol? *
Do you currently smoke? *
Do you currently use any other drugs? *
How often do you exercise? *
Are you currently pregnant? *
Are you planning a pregnancy or breastfeeding? *
GLP-1 medications are not considered safe during pregnancy or breastfeeding. If this applies to you, we can't proceed right now — but a clinician can discuss safe alternatives and timing.
One important question

Your wellbeing

We ask everyone this — your safety matters to us.

Are you currently experiencing any thoughts of suicide or self-harm? *
Your safety comes first. If you're having these thoughts, please reach out right now: call or text 988 (Suicide & Crisis Lifeline), available 24/7. You can also text HOME to 741741. We'll pause this application, and a member of our team will follow up with care.
Almost there

Tell us who you are

Last step before consent — your contact details so we can reach you.

Consent

Final step

Please review and agree before we submit your intake.

By signing below, I hereby acknowledge, agree, and authorize all of the following:

1. Accurate information. I certify that the information provided on this form is accurate, complete, and up to date to the best of my knowledge.

2. Weight-loss treatment. I confirm I am not currently pregnant, planning to become pregnant, or breastfeeding, and I agree to stop this medication immediately and notify my provider if I become pregnant. I will take the medication strictly as directed. I understand that weight-loss results vary depending on diet, exercise, genetics, and individual response, and that no specific amount of weight loss has been guaranteed to me.

3. Compounded medication. I understand that compounded medications are not approved by the FDA and have not been evaluated by the FDA for safety, effectiveness, or quality, and that they are prepared by a state-licensed pharmacy for an individual patient pursuant to a valid prescription.

4. Patient rights and responsibilities. I understand that the healthcare facility maintains a Notice of Privacy Practices, which describes how my protected health information may be used and disclosed, and how I may access my health records. I understand that I have the right to review this Notice prior to signing this form.

5. Release of medical information. I authorize the release of my health information to the healthcare facility in accordance with its Notice of Privacy Practices. This includes, but is not limited to, releasing medical information to my referring physician, primary care physician, and any physician(s) I may be referred to. The healthcare facility shall ensure all health information remains confidential, as required by HIPAA, and will not release any of my health information without my consent.

6. Consent for treatment. I grant the healthcare facility, including its affiliated providers, physicians, and other medical personnel, permission to use the health information provided for the purpose of my medical treatment as necessary.

7. Consent to communication. I consent to receiving communications from the healthcare facility regarding appointment reminders, test results, and other necessary healthcare-related information via phone, email, or other channels.

8. Acknowledgment. By signing below, I hereby acknowledge, agree, and authorize all of the above.