Before scheduling, see if you may qualify
Complete this brief form to estimate your BMI, identify potential clinical eligibility criteria, and screen for safety concerns before your online medical evaluation.
First, tell us about yourself
This information helps us prepare a summary for your medical evaluation.
See how much weight you could lose
We will use your height and weight to estimate your BMI, review eligibility for medical weight management, and provide an educational estimate of potential weight loss.
Do you have any of these conditions?
Select all that apply. This information helps assess clinical criteria and safety.
Have you had laboratory tests within the past year?
Your answer alone does not determine whether you qualify, but it helps us know whether recent results are available for review.
List any medications or supplements you currently take
Include prescription medications, over-the-counter medications, vitamins, supplements, or natural products.
List any allergies
Include allergies to foods, dyes, prescription or over-the-counter medications, antibiotics, herbs, vitamins, or supplements.
Which GLP-1 medications have you used before?
Select all that apply. This helps us review your previous response, tolerance, and safety.
Have you had weight-loss surgery or procedures?
This helps us understand your medical history and choose the safest option.
Safety: important medical history
Some conditions may require special review or may be contraindications.
Are you pregnant, breastfeeding, or trying to become pregnant?
This question is important for clinical safety.
Alcohol and recreational substance use
These questions help provide a complete picture of your health and safety before selecting treatment.
How often do you consume 5 or more alcoholic drinks on one occasion?
Which option interests you most?
The final decision depends on medical evaluation, availability, and eligibility.
Prequalification result
Summary to copy
This tool is for educational prequalification only. It does not establish a physician-patient relationship, provide a diagnosis, replace a medical evaluation or emergency care, or guarantee a prescription. All treatment depends on your medical history, contraindications, eligibility, safety, availability, and the clinician's medical judgment. If you are in immediate danger or experiencing severe symptoms, call 911 or go to the nearest emergency room.