Weight Loss Program - Initial Screening Form (Weeks 1-8)
Hi there! We are excited to share that we have officially expanded our Weight Loss Program to the states of Texas, Arizona, Florida, Colorado, New Mexico, Nevada, Utah, and Montana. If you reside in one of these eight states, please complete this form to be considered as a candidate for our Weight Loss Program! Upon candidacy, you will receive a Welcome Email outlining the next steps! 

NOTE: This program is only available to those residing in the states of Texas, Arizona, Florida, Colorado, New Mexico, Nevada, Utah, and Montana. All other state participants must travel to one of these eight states when attending the required launch call to complete onboarding and meet our licensing requirements (note: launch calls are held every Thursday at 11:30am, CST). Upon attending your first launch call physically in one of these eight licensed states; you can continue to participate in our Weight Loss Program back in your home state for the entirety of the time you are on program. If you cannot travel to either eight of these states in the near future; then you may still fill out this form, and it will serve as a waitlist to get your home state added to our Weight Loss Program in the potential near future. 
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Email *
Full name *
What is your date of birth? *
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What is your phone number?  *
Do you reside in the states of Texas, Arizona, Florida, Colorado, New Mexico, Nevada, Utah, or Montana? *
What is the shipping address we should use for the medication? You MUST write out your FULL complete shipping address including the Street Number & Street Name, Unit/ Apt. # (if applicable), City, State, Zip. 


***NOTE: Do not fill out this form if you are traveling or moving in the next two weeks. Please wait to complete this form to avoid your medication being delivered when no one will be at the listed address. It will be shipped on ice in temperature regulated packaging, but the medication still must be brought inside within the first few hours of arrival. No PO boxes! ***
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What is your current weight? *
What is your goal weight, or the weight you feel most comfortable?  *
What is your current height? *
Any known drug allergies? *
Are you currently being treated with insulin or any injectable diabetes medication? NOTE: This does not include GLP-1 injectables.  *
If you answered "Yes"  to the previous question, what insulin treatment or injectable diabetes medication are you currently taking? Please skip question if you answered "No."
What efforts have you attempted lifestyle or medication wise to lose weight?  *
Have you ever been diagnosed with an eating disorder?
 *
Have you ever been diagnosed with Gastroparesis?
 *
Do you or anyone in your family have a history of known medullary thyroid carcinoma? (note this is a very specific/rare type of cancer, not a general thyroid cancer diagnosis). *
Do you have a history of known multiple endocrine neoplasia?
 *
Have you had pancreatitis in the last 18 months?  *
Are you currently pregnant, breastfeeding, or plan to become pregnant in the next two months?  *
Do you agree to getting all necessary preliminary lab work and labs to monitor progress as necessary? *
What lab would you like for us to submit to for your baseline labs?: (CBC, CMP, HbA1c, insulin, lipid panel, HS-CRP) *
Our Pharmacy cannot ship directly to all 50 states. The list below are states our Pharmacy CANNOT send directly to. Is your shipping address located in one of these states? 

Alabama
Arkansas
California
Hawaii
Indiana
Michigan
Nebraska
Nevada
New Hampshire
South Carolina
Tennessee
Virginia
West Virginia

***Mississippi - This is the one state that we cannot accept into our Weight Loss Program. See question below.
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If your state was listed in the previous question, do you agree to an extra $130 shipping fee per order?  
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Refund & Return Policy: Refunds and Returns are not permitted with this medication. Due to medical safety, GLP-1 medication vials are not eligible to be returned. This applies to all opened, unopened, and used vials. All sales are final. Full or partial refunds cannot be issued, whether or not the purchased vial was opened, unopened, or used.  
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I certify that, to the best of my knowledge, that my provided answers on this form are correct. (Personal Info, Shipping Address, Medical History, Etc.)
 *
Thank you completing the above candidacy form for our Weight Loss Program! Upon form submission our team will screen your responses to ensure you meet location and medical requirements to join our Weight Loss Program! Upon candidacy, you will receive a Welcome Email outlining the next steps to join our program! So be on the look out in your email inbox, and ensure you also check your spam folders as well! 
We graciously look forward to serving you on your health journey TOGETHER! 
*The average turnaround time for candidacy screening is approximately 1 week from form submission to receiving a Welcome Email. 
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