GLP-1 Intake Form | VirtuallyWell

Personal Information

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth & Sex

Date of Birth *

Sex Assigned at Birth *

Pregnancy Screening

Are you currently pregnant? *

Yes No

Are you currently breastfeeding? *

Yes No

Body Measurements

Height (feet) *

Height (inches)

Weight (lbs) *

Shipping Information

Shipping State *

Medication Preference

Which medication are you interested in? *

Compounded Semaglutide (Injection) Compounded Tirzepatide (Injection) Not sure / Need guidance

GI/Endocrine Conditions

Do you have any of the following conditions? *

Kidney Conditions

Do you have any of the following conditions? *

Kidney failure Chronic renal failure Seen a kidney specialist in the last 12 months Solitary kidney or kidney transplant None of the above

Consent & Agreement

I understand that a licensed healthcare provider will review my information and contact me regarding eligibility for GLP-1 therapy. * I have read and agree to the Privacy Policy and Terms of Service. *

What happens next:
A licensed healthcare provider will review your information to determine whether treatment is medically appropriate. We will reach out to you via email to coordinate your assessment.

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