Your journey to sustainable health
starts here.
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GLP-1 meds
are Popular because they work!
In clinical trials, GLP-1 users lost an average of 15% of their body weight - with 1 in 3 users losing over 20%*
Please share your information to get started.
Nice to meet you,
Name
We're BariatricPal – a team dedicated to precise, personalized and proven solutions that work for YOU.
Next, we'll calculate your Body Mass Index (BMI).
If yes, please upload proof of your current prescription
If yes, which one are you taking?
(Please select)
When was your last dose?
(An estimate is fine!)
What was the strength of your last dose?
(In milligrams (mg) if you know it!)
How are you doing with your medication?
(Are you noticing any side effects? Is it working well for you? We'd love to hear your thoughts!)
Is there a particular medication you are interested in discussing with your provider?
(Please select).
Note: Compounded medications are prescribed after a licensed provider consultation and prepared by a 503A compounding pharmacy for individual use.
Are you pregnant, breastfeeding, or planning to be in the next 2 months?
(This helps us provide the safest recommendations!)
Please list all your current medications, including prescription, over-the-counter, and supplements, including dosages.
if you do not have any current medications, please type None or N/A.
Have you ever had surgery?.
(If so, please list them or type “N/A” if none.)
Please list all of your known allergies.
if you do not have any allergies, please type None or N/A.
Thanks for Sharing!
Now, let's talk about your weight loss journey so far and what you're hoping to achieve.
What weight loss initiatives have you tried in the past?
(select all that apply)
We Understand!
We know how hard it can be when you don't see results. Let's find a solution that truly works for you!
What are your weight loss goals?
(select all that apply)
We Hear You,
Name
We know how important it is to feel your best, and we're here to help you get there. Let's work together to achieve the lasting change you've been looking for.
Please upload a government issued form of ID (Driver's License, Passport, etc).
Please ensure the front of your ID is uploaded with your full name and photo clearly visible.
Similar to a doctor's visit, your ID is necessary for verification.
Which type of consultation do you prefer?
(Let us know what works best for you!)
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 are 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.
Great news, Name Name
You’re pre-qualified for medical review.
Now let’s finish up.
Add your card so we can set up your telehealth visit and prescription.
You won’t be charged today.
- If you’re approved and choose to move forward, the cost is $. No contracts. Cancel anytime. No gimmicks. No gotchas. Unlike others that lock you into long-term commitments.
- If you’re not approved, you won’t be charged.
Once your card is on file, we’ll review your answers and let you know in 1–2 business days. If eligible, you’ll get a link to schedule your video visit.
Payment authorization successful.
We've got you covered
