GLP Intake Form & GLP Clinical Difference Intake 1. What is your primary goal for weight loss? Overall health improvement Specific weight loss target Increased energy Improved body compositionPreviousNext2. How much weight would you like to lose? 10-20 lbs 20-30 lbs 30-40 lbs 40-50 lbs 50+ lbsPreviousNext3. How often do you exercise? 1-2 times per week 3-4 times per week 5+ times per week NeverPreviousNext4. Are you willing to follow a weight loss dietary plan/reduce calories and exercise? Yes NoPreviousNext4.1) I acknowledge that GLP medications are most effective when used in conjunction with exercise Yes NoPreviousNext5. Have you had any previous weight loss attempts or programs? Yes NoPreviousNext5.1) Please select the statement that best describes your previous weight loss attempts. Was able to lose weight and kept off the weight for a while Was able to lose weight but regained the weight shortly after Was unable to lose even though I followed my dietary and exercise goals Was unable to lose weight and I was unable to follow my dietary and exercise goalsPreviousNext6. Have you been diagnosed with any eating disorders or have a history of disordered eating? Yes, currently diagnosed Yes, in the past No, but I have experienced disordered eating behaviors No, neverPreviousNext6.1) Have you been diagnosed with any eating disorders or have a history of disordered eating? Binge Eating Bulimia Anorexia Nervosa OtherPreviousNext6.1.1) What were you diagnosed with?PreviousNext6.2) What were you diagnosed with? Binge Eating Bulimia Anorexia Nervosa OtherPreviousNext6.2.1) What were you diagnosed with? How long has it been since you were diagnosed? Less than 12 months ago More than 12 months agoPreviousNext6.2-3) (History of Anorexia is a disqualifier for treatment)[hld_disqualify] PreviousNextNow Let's find which treatments you are eligible for First you'll need an account with usEnter EmailContinueContinueAlready have an account? Sign InContinue with GoogleBy creating an account using email, Google or Apple, I agree to the Terms & Conditions and acknowledge the Privacy Policy.PreviousNext2. Have you attempted any of the following in the past to lose weight? (Please select all that apply) Fitness trackers Calorie-counting apps Gym or exercise Meal planning tools Restrictive eating Nutritionist or dietician Prescription medication Food delivery services Professional Therapy None of the abovePreviousNext3. Why do you want to lose weight? (Please select all that apply) Increase self-confidence Feel better in clothes Have more energy Look more attractive Enhance physical performance Reduce disease risk OtherPreviousNext4. What is your goal weight (in pounds)? Where would you like to be?PreviousNextSave & Resume5. Do any of the following apply to you? (Please select all that apply) Eating disorder Acute hepatitis or liver failur Substance abuse or dependency Alcohol use None of the abovePreviousNextThanks for completing your Healsend quiz! Based on your answers, you may not qualify for our GLP-1 program at this time — but your health journey doesn’t stop here. We’re always adding new ways to support your goals. There may be other options that are a better fit for you Explore wellness options or check back soon — we’re here when you're ready.PreviousNext6. How much alcohol do you drink? 3+ drinks per day 1-2 drinks per day 1-2 drinks per week 3-5 drinks per week NonePreviousNextThanks for completing your Healsend quiz! Based on your answers, you may not qualify for our GLP-1 program at this time — but your health journey doesn’t stop here. We’re always adding new ways to support your goals. There may be other options that are a better fit for you Explore wellness options or check back soon — we’re here when you're ready.PreviousNext7. Do you suffer from any of these medical conditions? (Please select all that apply) Heart disease HTN Gallbladder disease Fatty liver disease Hyperthyroidism Glaucoma None of the abovePreviousNextThanks for completing your Healsend quiz! Based on your answers, you may not qualify for our GLP-1 program at this time — but your health journey doesn’t stop here. We’re always adding new ways to support your goals. There may be other options that are a better fit for you Explore wellness options or check back soon — we’re here when you're ready.PreviousNext8. Do you currently take any of the following medications? (Please select all that apply) MAOI’s (e.g., selegiline, pheneizine) Other weight loss drugs (e.g., amphetamine, dextroamphetamin, benzphetamine) SSRI’s (e.g., fluozetine, sertraline, paroxetine, citalopram, escitalopram, duloxetine, venlafaxine) Insulin Oral diabetic drugs (e.g., glimepiride, glipizide, sitagliptin) GLP’s (tirzepatide, semaglutide, liraglutide) Other medication None of the abovePreviousNextThanks for completing your Healsend quiz! Based on your answers, you may not qualify for our GLP-1 program at this time — but your health journey doesn’t stop here. We’re always adding new ways to support your goals. There may be other options that are a better fit for you Explore wellness options or check back soon — we’re here when you're ready.PreviousNext9. Are you currently? Pregnant Planning to become pregnant Breastfeeding None of the abovePreviousNextThanks for completing your Healsend quiz! Based on your answers, you may not qualify for our GLP-1 program at this time — but your health journey doesn’t stop here. We’re always adding new ways to support your goals. There may be other options that are a better fit for you Explore wellness options or check back soon — we’re here when you're ready.PreviousNext10. Use of Phentermine poses risks to those who can potentially become pregnant. Simultaneous use of at least one form of birth control is required in order to be prescribed Phentermine. Please select which form of birth control you will be using. Birth control pills IUD N/A - I am biologically malePreviousNext Please upload a photo of your birth control bottle.Photo PreviousNext11. I acknowledge that use of Phentermine medication without birth control can lead to birth defects for those who may become pregnant while on the medication. I agree to inform my provider and discontinue any treatment involving Phentermine if I become pregnant. Yes N/A - I am biologically malePreviousNext12. Primary pulmonary hypertension warning: This drug can cause PPH (primary pulmonary hypertension). This is a rare lung disease that may cause death. PPH is a type of high blood pressure that affects the arteries in your lungs and the right side of your heart. Symptoms can include shortness of breath, heart palpitations (fast, fluttering heartbeat), dizziness, bluish color to your lips and skin, tiredness and swelling of your legs and ankles. I understand and wish to proceed.PreviousNext13. Valvular heart disease warning: This drug may harm your heart valves. Your valves may not be able to close properly and may leak. This may interrupt the blood flow through your heart to your body. Symptoms can include fatigue and weakness, shortness of breath during activity or when you lie down, swollen ankles and feet, chest pain, and an irregular or fast heartbeat. I understand and wish to proceed.PreviousNext14. Misuse and dependence warning: This drug may be habit-forming. You should not take it long-term. The length of time is a few weeks to 12 weeks maximum. I understand and wish to proceed.PreviousNextShipping Information Please provide your shipping information. Your medication will be delivered to this address.First NameLast NameAddress Line 1CityStateZip CodePhone/MobilePreviousNext🎯 You’re In — Just One Quick Step to Start Treatment You’ve been pre-approved for compounded GLP-1 therapy — including semaglutide or tirzepatide, if clinically appropriate. ⚖️ A short video consult is required in your state before we can finalize your prescription. ✅ Takes less than 10 minutes✅ Secure callback and email within ~3 hours✅ Fully online — no apps, no waitrooms. ✔️ Once the visit is done, you’re ready to begin. 👉 Tap below to confirm and lock in your spot.PreviousNextA Modern Treatment Solution Opt-in for SMS notificationsGet text messages with important updates from healsend. Prescription expiration reminders Latest offers and treatments Updates from your healthcare provider Shipping and order updates Lab results, if applicable No thanksPreviousNextSelect the subscription plan that works best for you 3-Month Contract Month to month 12-month ContractPackages Details Please note that to select a specfic selection you can use the above ooptions Month to Month Package Save $280 $197 first month, $297/month thereafter A flexible plan to support your treatment at every stage. 6-Month Contract Save $280 $167 first month, $267/month thereafter* Subscribe to Save: A long-term program for continued transformation. 12-Month Contract Save $700 $147 first month, $247/month thereafter* Subscribe to Save: A comprehensive program for enduring results and sustainable health. PreviousNextPayment Method Month to Month Package Save $280 $197 first month, $297/month thereafter A flexible plan to support your treatment at every stage. 6-Month Contract Save $280 $167 first month, $267/month thereafter* Subscribe to Save: A long-term program for continued transformation. 12-Month Contract Save $700 $147 first month, $247/month thereafter* Subscribe to Save: A comprehensive program for enduring results and sustainable health. Secure your free evaluation.You will not be charged unless prescribed medication. Order Summary Provider evaluation Free Due today $0 Enter your card details Make Payment and SubmitConfirm and Continue Previous
