Free Assessment

Start your eligibility assessment

Answer a few questions and a licensed provider will review whether compounded GLP-1 therapy is right for you. Takes about five minutes, no payment required to get started.

Why we ask

This information helps a licensed provider evaluate your eligibility safely. Everything you submit is kept confidential and used only for your medical review.

Step 1 You submit this secure form
Step 2 A provider reviews your responses
Step 3 We contact you with next steps
Step 4 If prescribed, your medication ships to you

Not an emergency service. Submitting this form does not create a provider-patient relationship or guarantee a prescription.

First name *

Last name *

Email *

Phone *

Date of birth *

State of residence *

Height *

Current weight (lbs) *

Which treatment are you interested in? *

Goal weight (optional)

Current medications (optional)

Known medical conditions or allergies (optional)

Do you have a personal or family history of medullary thyroid cancer (MTC) or MEN 2? *

Your information is private and secure.