Excellent 4.5

Reach your goal weight fast without restrictive diets and exercise.

Please answer the following questions so we can qualify you for medical weight loss.

What is your height and weight?

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Are you male or female?

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What is your date of birth?

For your safety, the year entered may disqualify you from a prescription

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Do any of these apply to you?

For your safety, this answer may disqualify you from a prescription

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Health Questions 1

Do any of these apply to you?

For your safety, this answer may disqualify you from a prescription

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Health Questions 2

Do any of these apply to you?

Please provide some more information about your medication allergy:

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For your safety, this answer may disqualify you from a prescription

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Within the last 3 months, have you taken opiate pain medications and/or opiate-based street drugs?

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Have you had prior weight loss surgeries?

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Do you currently take any prescription medications?

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What is your blood pressure range?

For your safety, this answer may disqualify you from a prescription

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What is your average resting heart rate?

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Excellent 4.5

"When nothing else worked… MEDVi did!"

Are you ready for your next chapter?

Excellent 4.5

With medication, you'll lose {weekly_weight_loss} to {more_weekly_weight_loss} pounds per week.

It will take about {time_to_hit_goal} weeks to reach your goal weight of {goal_weight}.

How is that pace for you?

Excellent 4.5

Perfect!

Losing {weight_loss}lbs is easier than you think - and it doesn't involve restrictive diets.

Excellent 4.5

Not a problem, we can move faster.

It will take some work, but with GLP-1 medication, your goal to lose {weight_loss}lbs can be achieved in about

{faster_time_to_hit_goal} weeks - and it doesn't involve restrictive diets.

Excellent 4.5

We'll move at your pace.

With GLP-1 medication, your goal to lose {weight_loss}lbs is easier than you think - and it doesn't involve restrictive diets.

Excellent 4.5

Have you taken medication for weight loss within the past 4 weeks?

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Excellent 4.5

Great! You have experience with GLP-1.

Please list the name, dose, and frequency of your GLP-1 medication.

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When was your last dose of medication?

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What was your starting weight in pounds?

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Please take or upload a photo of your GLP-1 medication

If you are requesting a prescription for your current or higher dose, this is important. If you don't have a photo available, you can skip this.

Do you agree to only obtain weight loss medication through this program moving forward?

It's important not to "stack" weight loss medications.

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Excellent 4.5

Great! You have experience with weight loss medication.

Please list the name, dose, and frequency of your GLP-1 medication.

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What was your starting weight in pounds?

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Do you agree to only obtain weight loss medication through this program moving forward?

It's important not to "stack" weight loss medications.

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Excellent 4.5

How about weight loss programs?

Have you ever tried to lose weight in a weight management program (Jenny Craig, Weight Watches, etc)?

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Excellent 4.5

Your needs are unique, and your medicine should be too!

Your GLP-1 medication is personalized to your specific needs

Please select the following options that you are interested in.

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Excellent 4.5

MEDVi medical providers review every form within 24 hours

Do you have any further information which you would like our medical team to know?

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GLP-1 Treatment
Assessment Complete
Ready for Review

Assessment Complete

Congratulations! You're a strong candidate for medical weight loss treatment.

Your Medical Review

Success Probability

94%

BMI: {bmi}

Current Weight: {starting_weight}lbs

Goal Weight: {goal_weight}lbs within {time_to_hit_goal} weeks

You are a strong candidate for medical weight loss treatment.

Let's proceed to check your eligibility.

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Your information is never shared and is kept confidential.

Excellent 4.5

{first_name}, how can you be reached if necessary?

Our medical teams and pharmacy use email and text for patient communication.

Excellent 4.5

Eligibility Status

Based on your last answer, we cannot complete your assessment.
Your safety is our priority. This treatment has specific medical criteria, and your response prevents our clinicians from safely determining your eligibility.

Made a mistake? Review your answer

If your answer was correct, we cannot continue this assessment.

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