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Pre-Qualification for GLP-1

Please answer all questions honestly! These questions are designed to prevent complications that could harm you if you're not honest. Thank you and we are looking forward to working with you on your journey to weight loss. We encourage you to answer all questions with complete honesty. Your genuine responses are crucial for ensuring your safety and preventing any complications on your journey. Thank you for your cooperation; we are excited to support you as you embark on your weight loss journey!

Are you between the ages of 18 & 70?
Yes
No
Are you currently pregnant or breastfeeding?
Yes
No
Are you planning to get pregnant in the next two months?
Yes
No
Do you have a history of, or are you currently being treated for any of the following?
Do you have any of the following health conditions that are uncontrolled:
Have you had gastric bypass, duodenal switch, lap band, or a gastric sleeve?
Yes
No
Are you currently taking insulin, Glipizide, or SGLT2 inhibitors?
Yes
No
Do you consent to be treated with a GLP-1 agonist (Semaglutide, Tirazepatide)?
Yes
No
Are you willing to make lifestyle modifications including decreased caloric intake and exercise along with your medication?
Yes
No
Have you previously experienced serious or uncontrollable side effects while taking Semaglutide or Tirzepatide?
Yes
No
Is your BMI below 27? need help finding your bmi? https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm)
Yes
No
Do you currently have any desire to harm yourself or others?
Yes
No
Are you currently living in Alabama or Mississippi?
Yes
No
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