GLP-1 Patient Intake

Complete this form so our care team can prepare for your free consultation. This is not a prescription — your provider reviews and approves all therapy.

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Intake received, {{ thanksName }}.

Your email app should have opened with your intake ready to send. Our care team will follow up to schedule your consultation and confirm next steps.

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Patient Information

First name*

Last name*

Date of birth*

Phone*

Email*

Shipping Address

Street address*

City*

State*

ZIP*

Program of Interest

Select the medication you're interested in. Your provider will confirm the right starting dose during your consultation — nothing is dispensed without provider approval.

Add anti-nausea support — Ondansetron 4 mg ODT (as needed)

Delivery Preference

Allergies & Notes

Please note: Compounded formulations are chosen to help reduce nausea compared with commercially supplied product. Typical starting therapy is one weekly subcutaneous injection as directed (28-day supply). Final medication, dose, and instructions are determined by your provider.

Serving all states excluding California. By submitting you consent to be contacted by our care team.