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Since these are prescription meds, we need to ask a few health questions.

Why we ask: Your answers help the licensed clinician determine if treatment is right for you.

Here's how it works:

  • Answer a few quick questions
  • Complete your order and checkout
You're charged only if the medication is shipped. If your doctor determines the treatment isn't right for you, your order will be canceled automatically and you'll receive a full refund—simple, secure, and stress-free.
Your privacy matters. All provided information is securely encrypted and accessible only by a licensed Canadian clinician and pharmacist, ensuring strict compliance with privacy and confidentiality regulations.

Weight Loss Questionnaire

What was your sex assigned at birth?

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Weight Loss Questionnaire

Are you currently pregnant, breastfeeding or planning to become pregnant?

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Weight Loss Questionnaire

Read the following for more information about this product and its potential side effects:

It is not safe to take these medications while pregnant or breastfeeding. The FDA advises that these medications may pose a risk to a developing fetus.

Oral contraceptives alone may not be effective, as the medication could reduce their effectiveness.

The FDA specifically recommends continuing oral contraception alongside a barrier method (like condoms) for the first month after starting a weight loss medication and for the first month after any dose increase.

Alternatively, you can switch to a non-oral contraceptive method (such as an IUD or implant) before beginning the medication. After stopping the medication, you should continue using a backup method, such as condoms, for two months to ensure the medication has fully cleared your system before trying to conceive. Additionally, its safety during breastfeeding is unknown, so if you are nursing, consult your doctor to explore safer weight loss options.

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Weight Loss Questionnaire

What is your height in feet and inches?

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Weight Loss Questionnaire

What is your weight in pounds?

Please input only numbers.

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Weight Loss Questionnaire

Consent (BMI):

Weight loss medications are traditionally prescribed for individuals with a BMI of 30 or higher, or for those who are overweight (BMI 25–29) with a related health condition. Using these medications for someone in the 25–29 BMI range without another health condition is considered "off-label" use. This means the medication is being prescribed in a way not specifically approved by the U.S. Food and Drug Administration (FDA). Please follow your prescribed regimen closely and report any side effects or concerns.

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Weight Loss Questionnaire

Please check all current or past medical conditions:

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Weight Loss Questionnaire

Consent (gallbladder) - Read the following for more information about this product and its potential side effects:

Gallbladder disease information:
You noted that you have gallbladder disease or previous removal of our gallbladder. This medication may still be a good option. However, this medication can affect how the body handles fats and bile. If you have had your gallbladder removed, the body's ability to store and release bile is altered. Bile is crucial for digestion and fat absorption. This medication may increase the likelihood of gastrointestinal side effects in these individuals because it can alter fat metabolism and bile flow. This can lead to symptoms such as diarrhea and stomach pain.

Additionally, medications that affect digestion and appetite, like this medication, might alter the absorption and metabolism of other nutrients (like fat soluble vitamins such as vitamin A, D, E, and K) and medications. This is particularly important for those without a gallbladder, as their digestive system already operates differently from those with a functioning gallbladder. If you wish to move forward, it is important to eat smaller and more frequent meals. In addition, to ensure that you're receiving enough vitamins, you should avoid processed foods while eating plenty of fruits and vegetables, as well as considering the use of a multi-vitamin unless told by your provider to avoid these for other reasons.

If you have asymptomatic gallstones, please note that these medications and weight loss itself may result in gallstone formation which could result in the obstruction of the normal flow of bile which can result in infection, pancreatitis, and/or emergent need for gallbladder removal. It is important to receive prompt medical evaluation if symptoms appear as delayed action may result in serious harm or death if untreated.

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Weight Loss Questionnaire

Please tell us more about your medical condition(s) that you selected

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Weight Loss Questionnaire

Have you had a gastric bypass in the past 6 months?

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Weight Loss Questionnaire

Are you allergic to any of the following?

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Weight Loss Questionnaire

Do you take any of the following medications?

  • Insulin
  • Glimepiride (Amaryl)
  • Meglitinides such as repaglinide or nateglinide
  • Glipizide (Glucotrol and Glucotrol XL)
  • Glyburide (Micronase, Glynase, and Diabeta)
  • Sitagliptin
  • Saxagliptin
  • Linagliptin
  • Alogliptin

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Weight Loss Questionnaire

Are you currently, or have you in the past two months, taken any of the following medications?

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Weight Loss Questionnaire

Which medication and dose most closely matches your most recent dose?

  • Tirzepatide = Mounjaro, Zepbound
  • Semaglutide = Ozempic, Wegovy

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Weight Loss Questionnaire

How would you like to continue your treatment?

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Weight Loss Questionnaire

Do you have a picture of your current prescription? We need this photograph in order to validate your current dosage.

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Weight Loss Questionnaire

Please upload a picture of the prescription or bottle of your current GLP-1/GIP medication

Upload preview

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Weight Loss Questionnaire

What other information or questions do you have for the doctor?

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Weight Loss Questionnaire

Full Body Image

To ensure the highest quality of care during your telemedicine consultation, we kindly request your assistance in providing a full-body clothed photo of yourself (please remain clothed but avoid wearing baggy apparel). The image should include your face to help facilitate verification of your identity. Please be assured that these images will remain private and will not be shared. The physician will use the picture solely for assessment purposes to better understand your health condition. Thank you for your cooperation and understanding in helping to provide comprehensive care remotely.
(Tip: using a full length mirror can help you capture this image)
Upload preview

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Weight Loss Questionnaire

Consent (Truthfulness)

Please attest to the following confirming that all information you have provided to us is true and complete.

I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.

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Weight Loss Questionnaire

Consent (GLP-1 and GLP-1/GIP)

Indication for Use:

You are requesting treatment with a GLP-1 (Ozempic, Wegovy, or compounded semaglutide) or GIP/GLP-1 receptor agonist (Mounjaro, Zepbound, or compounded tirzepatide) medication as part of your treatment plan for the management of weight or obesity. These medications work by mimicking the action of incretin hormones, which help regulate blood sugar levels, promote feeling full, and reduce food intake.

Potential Benefits:

  • Weight loss or weight management
  • Improved blood glucose control
  • Reduced cardiovascular risk
  • Potential improvement in overall metabolic health

Potential Side Effects:

While these medications can be beneficial, they may also cause side effects. Although not common, these medications can result in emergency room visits, hospitalizations, or even death. Common and serious side effects include, but are not limited to:

  • Common Side Effects:
    • Nausea
    • Vomiting
    • Diarrhea
    • Constipation
    • Decreased appetite
    • Indigestion
  • Serious Side Effects:
    • Pancreatitis (inflammation of the pancreas)
    • Hypoglycemia (low blood sugar), especially when used with other diabetes medications
    • Gallbladder disease (e.g., gallstones)
    • Kidney problems
    • Allergic reactions (e.g., rash, itching, swelling)
    • Gastroparesis (paralysis of the bowels)

Risks and Considerations:

  • Pancreatitis: There is a risk of developing pancreatitis. If you experience severe abdominal pain, nausea, or vomiting, you should contact your healthcare provider immediately.
  • Thyroid Tumors: Animal studies have shown an increased risk of thyroid tumors with certain GLP-1 medications. Although this has not been confirmed in humans, please inform your healthcare provider if you have a history of thyroid cancer.
  • Hypoglycemia: When taken with other diabetes medications, particularly insulin or sulfonylureas, there is a risk of low blood sugar. It is important that your provider knows if any of these medications are added to your regimen.
  • Kidney Function: This medication may affect kidney function, particularly in patients with existing kidney disease. Regular monitoring of kidney function may be required.

Monitoring and Follow-up:

You will require regular follow-up visits to monitor your response to the medication and to assess for any side effects. We may intermittently ask for full-body selfie images to ensure that your reported weight is consistent.

I acknowledge the potential benefits, risks, and side effects of GLP-1 or GIP/GLP-1 receptor agonist medications. I understand the importance of regular monitoring and follow-up appointments. I consent to the use of GLP-1 or GIP/GLP-1 receptor agonist medications as part of my treatment plan for overweight or obesity.

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Acknowledgement

Not Eligible Right Now Based On Your Answers

We understand and respect your decision not to consent to PDE5 inhibitors at this time.

These medications are a common, safe, and effective treatment for ED, as they work by improving blood flow.

If you'd like to reconsider, simply hit the back button. You can also revisit this option anytime and we're happy to provide more information and explore your choices together in a way that feels right for you.

Go Back To Questionnaire

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Acknowledgement

Pharmacy Consent

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