Start your GLP-1 program in under 5 minutes.
Complete the form below. A US-licensed provider reviews every submission — typically within 48 hours. No in-person visit required.
GLP-1 Pre-Consult Intake Form
All fields are reviewed by a US-licensed provider. Your information is transmitted securely and handled in compliance with HIPAA.
What happens next?
Once you submit, a US-licensed provider reviews your information within 48 hours. If approved, your medication is prescribed and shipped directly to you. Some states may require a brief phone or video consultation first.
Your information is safe
All data is encrypted in transit and stored in compliance with HIPAA. We never sell your information. See our Privacy Policy and HIPAA Notice.
No guarantee of prescription
Submitting this form does not guarantee approval or medication access. All treatment decisions are made independently by a licensed healthcare provider based on your clinical history.
AI is not involved in clinical decisions
Automated tools may assist with scheduling and reminders, but they do not diagnose, prescribe, or make clinical decisions. See our AI Communication Notice.
Questions about the intake?
Most patients complete it in under 5 minutes. You'll provide basic health information, medical history, and current medications. Have your medication list handy to move faster.
The form does not save progress. We recommend completing it in one sitting. It's brief — most patients finish in a few minutes.
No. This is a cash-pay program. No insurance is required, accepted, or billed. Pricing is transparent and listed on our homepage.
A US-licensed provider reviews your submission. Based on your clinical history, you'll be routed to one of two paths: either a confirmed treatment plan with your prescription shipped directly to you, or a brief provider consultation if your state or clinical profile requires one. You'll be notified either way.
No. Submitting an intake form does not guarantee approval, eligibility, or medication access. All clinical decisions are made independently by a licensed healthcare provider. See our Terms of Use.
Prefer to speak with a provider first? You can schedule a consultation instead of completing the form online.
Book a Provider Consultation