Are You Qualified

GLP-1 Eligibility & Dosage Assessment

Full Name:

Email:

Mobile Number:

Date of Birth:

Sex: Select Male Female Other

Street Address:

Country to Ship To: Select USA Canada UK Jamaica Other

Height:

Weight (lbs):

Goal Weight (lbs):

Your BMI: --
Recommended Dosage: --

Start Date of Treatment:

Treatment Duration (weeks):

Currently using a GLP-1 medication? Yes No

If yes, product and dosage:

Do you have any of the following? (Type 'No' if none)

Currently using any medications? (List all or type 'No')

Experiencing any of the following symptoms? (or type 'No')

Do you have high blood pressure? Select Yes No

Do you have kidney or liver problems? Select Yes No

Do you have any known allergies to medications?

How many meals do you eat per day?

Do you frequently eat late at night? Select Yes No

Do you consume sugary drinks daily? Select Yes No

I agree to the terms and conditions.

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