Skip to main content
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 4
1
Check Eligibility
Your Information
We made this easy for you.
Full Name
*
Email Address
*
Phone Number
Date of Birth
Height
Weight
Ethnicity
Birth Gender
Next
2
Continue Eligibility
Additional Information
Layout
Are You Pregnant?
Are You Pregnant?
Yes
No
Are you currently on weight loss medication?
Are you currently on weight loss medication?
Yes
No
What medication and dose?
Do any of the following apply to you?
Do any of the following apply to you?
None
High Blood Pressure (Hypertension)
High Cholesterol (Hyperlipidemia)
Prior Bariatric Surgery
Pre-diabetes/Type 2 Diabetes
Prior Stroke/TIA or Coronary Artery
Disease
History of Medullary Thyroid Cancer
History of Pancreatitis
Previous
Next
3
You’ve Got Options
Tell Us What’s Most Important To You
Select All That Apply
Select All That Apply
Losing Weight
Improving physical health
Improving another health condition
Increasing confidence
Establishing healthier habits
*
By subscribing, you are agreeing to our
Privacy Policy.
*
Please check this box to indicate that you agree to the
Terms and Conditions
,
Patient Agreement
and
Telehealth Consent.
Previous
Checkout
4
Let’s Get Started
It’s Time To Checkout.
Choose Product
*
Semaglutide
Tirzepatide
Choose Program
*
1 month - $299.00
3 month - $750.00
Choose Program
*
1 month - $449.00
3 month - $1,199.00
Total
$0.00
Stripe Credit Card
*
Submit
Close Menu
Home
About
Services
Primary Care
Medical Weight Loss
Aesthetics
Insurance
Team/Providers
Payment Plans
Blog
Contact
Am I Eligible?
