Reach your goal weight fast without restrictive diets and exercise.

Please answer the following questions so we can qualify you for medical weight loss.

What is your height and weight?

Feet

Inches

Weight (in kg)

What is your goal weight? (in kg)

Are you male or female?

♂

Male

♀

Female

What is your date of birth?

Month

Day

Year

Do any of these apply to you?

Currently or possibly pregnant, or actively trying to become pregnant Breastfeeding or bottle-feeding with breastmilk Have given birth to a child within the last 6 months None of the above

Health Questions 1

Do any of these apply to you?

End-stage kidney disease (on or about to be on dialysis) End-stage liver disease (cirrhosis) Current suicidal thoughts and/or prior suicidal attempt Cancer (active diagnosis, active treatment, or in remission or cancer-free for less than 5 continuous years — does not apply to non-melanoma skin cancer that was considered cured via simple excision) Severe gastrointestinal condition (gastroparesis, blockage, inflammatory bowel disease) Current diagnosis of or treatment for alcohol, opioid, or substance use disorder/dependence None of the above

Within the last 3 months, have you taken opiate pain medications and/or opiate-based street drugs?

✓

No

✕

Yes

Have you had prior weight loss surgeries?

✓

No

✕

Yes

Do you currently take any prescription medications?

✓

No

✕

Yes

Please list your current medications

What is your blood pressure range?

💧

< 120/80

Normal

💧

120 – 129/<80

Elevated

🩸

130 – 139/80–89

Hypertension Stage 1

🩸

≥ 140/90

Hypertension Stage 2

What is your average resting heart rate?

❤️

<60 beats per minute

Slow

❤️

60 – 100 beats per minute

Normal

❤️

101 – 110 beats per minute

Slightly Fast

❤️

>110 beats per minute

Fast

With medication, you'll lose 1–1.5 kg per week.

It will take about — weeks to reach your goal weight of — kg.

How is that pace for you?

✓

That works for me

🏃

I want it faster

⏱

That's too fast

Perfect!

Losing weight is easier than you think — and it doesn't involve restrictive diets.

Have you taken medication for weight loss within the past 4 weeks?

Yes, I've taken GLP-1 medication

Yes, I've taken a different medication for weight loss

No

Great! You have experience with GLP-1.

Please list the name, dose, and frequency of your GLP-1 medication.

When was your last dose of medication?

What was your starting weight in pounds?

Please take or upload a photo of your GLP-1 medication

If you are requesting a prescription for your current or higher dose, this is important. You can skip this if no photo is available.

⬆

Click to upload file or drag-and-drop. Max 15 MB

Do you agree to only obtain weight loss medication through this program moving forward?

It's important not to "stack" weight loss medications.

✕

No

✓

Yes

How about weight loss programs?

Have you ever tried to lose weight in a weight management program (Jenny Craig, Weight Watchers, etc)?

✓

Yes

✕

No

Your needs are unique, and your medicine should be too!

Your GLP-1 medication is personalised to your specific needs

Please select the following options that you are interested in.

Maintaining muscle mass as I lose weight Would prefer not to inject Managing potential side effects such as nausea/vomiting Assist with aging and longevity (cellular/DNA damage, immune system dysfunction, etc) Improving cognitive function and mental clarity Improving energy levels Regulating menses and hormonal status Improving sleep quality I'm not sure — I'd like to discuss formulation options with a clinician via a live virtual consult

RCP medical providers review every form within 24 hours

Do you have any further information which you would like our medical team to know?

✓

Yes

✕

No

Your Medical Review

Success Probability

94%

🏃

BMI:

—

⚖️

Current Weight:

—

🎯

Goal Weight:

—

You are a strong candidate for medical weight loss treatment.

Let's proceed to check your eligibility.

First Name

Last Name

State / Region

How can you be reached if necessary?

Our medical teams and pharmacy use email and text for patient communication.

Email

Phone Number

🏥 HIPAA Compliant

🔒 Secure & Private

⚕️ Doctor-Led