MTC Initial Semaglutide - Weight Loss Screening Form (Weeks 1-8)

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Hi there! Please complete this form if you are currently a Modern Thyroid Patient, and would like to be considered as a candidate for our Semaglutide Weight Loss Program. This form is for the STARTING dosage or for those who are restarting our program after taking a break. Upon candidacy you will receive an invoice to start our program.

*Note: The only state we cannot serve is Mississippi.

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Correo electrónico *

Full name: *

What is your date of birth? *

AAAA

What is your phone number? *

Are you currently a package patient of McCall McPherson?

*For patients who have paid for the Complete Concierge Thyroid + Hormone Care, or the Exclusive One on One Full Thyroid + Hormone Health Package with McCall McPherson.

Yes

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! ***

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. *

Yes

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? *

Yes

Have you ever been diagnosed with Gastroparesis? *

Yes

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). *

Yes

Do you have a history of known multiple endocrine neoplasia?
*

Yes

Have you had pancreatitis in the last 18 months?
*

Yes

Are you currently pregnant, breastfeeding, or plan to become pregnant in the next two months? *

Yes

N/A

Do you agree to getting all necessary preliminary lab work and labs to monitor progress as necessary? *

Yes

What lab would you like us to send a lab order to for your baseline labs?: (CBC, CMP, HbA1c, insulin, lipid panel, HS-CRP) *

LabCorp

Quest

CPL

Generic

BLT (Cash Pay Labs)

*Only for patients who have recently had an appointment:* Add SG labs to my existing lab order that was put in by my MTC provider to avoid multiple orders and confusion at the lab. NOTE: If you select this option and don't have an existing open order; a generic order will be created by default.

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.

No, my state is not listed here.

Yes, I am located in one of the above states.

I live in Mississippi

If your state was listed in the previous question, do you agree to an extra $130 shipping fee per order? *

My state was NOT listed in previous question, so I am not subjected to an additional $130 shipping fee.

Yes, I agree to paying an additional $130 per vial order to have my medication rerouted to me from MTC's office address.

No, I do not agree to paying an additional $130 per vial order. Therefore I acknowledge I will not be able to receive my medication due to this, or be a candidate for the Weight Loss Program.

I live in Mississippi: Semaglutide cannot be sent to your home state due to the Mississippi Board of Pharmacy rules and regulations. You cannot order Semaglutide with MTC.

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. *

I acknowledge and will abide by the clinic's Refund and Return Policy.

I certify that, to the best of my knowledge, that my provided answers on this form are correct (personal information, shipping address, medical history, etc). I also acknowledge that this order form is for the STARTING dose to start the program, or continue after taking a break. *

Yes, I have confirmed the accuracy of my responses and want the starting dose.

Thank you for completing the candidacy form for our Modern Thyroid Clinic's Weight Loss Program! Upon submission of this form, our team will carefully review your responses to ensure that you meet the medical requirements to join our program. Upon approval of your candidacy, you will receive an Invoice from Square (delivered by email) to purchase your two-month supply of medication. Once payment is received, we will promptly submit your order to the pharmacy for processing of your script. We graciously look forward to serving you on your health journey TOGETHER!

*The average turnaround time for candidacy screening is approximately one week. In additional, the average processing time for your medication is approximately 5 to 10 business days from the payment of your invoice to its arrival at your shipping address.

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