Semaglutide Therapy Request Form

Name *

First

Last

Email *

Phone

Mobile number preferred for SMS communication

Name of patient(s)

Leave blank if not applicable

Date to begin therapy

Date

Time

Address of patient

Address Line 1

Address Line 2

City

State

Zip Code

We are only licensed in the states of AZ, CA, CO, FL, IL, TX, NY, and GA at this time

Location type?

Parking at location?

Level of urgency for this request?

All requests considered emergency level should contact 911 immediately

Which IV therapies would you like to request?

Age of patient(s)

Use comma to separate for multiple patients

Does the patient(s) have symptoms of COVID-19?

Has the patient(s) tested positive for COVID-19?

How did you hear about us?

Anything else we should know about?

Please upload your lab results

Click or drag a file to this area to upload.

We are unable to provide a treatment plan without providing current lab results