Eligibility Assessment

Answer a few questions to prepare for your physician consultation. A licensed physician will review your responses and conduct a live telehealth visit to evaluate whether GLP-1 therapy may be appropriate for you. This takes about 3 minutes.

Your information is kept confidential and handled in accordance with HIPAA regulations.

Step 1 of 6

Your Information

Let's start with the basics.

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth *

Step 2 of 6

Shipping Address

Where should medication be shipped if prescribed?

Street Address *

Apt / Suite / Unit

City *

State *

Zip Code *

Step 3 of 6

Medical History

This helps our physicians evaluate your eligibility.

Do you have any medical conditions we should be aware of? *

Yes No

Have you ever been diagnosed with or hospitalized for pancreatitis? *

Yes No

Are you currently taking any medications? *

Yes No

Do you have any known medication allergies? *

Yes No

Step 4 of 6

Diabetes & Family History

These questions help determine program suitability.

Do you currently take insulin for diabetes management? *

Yes No

Have you been diagnosed with Type 1 diabetes? *

Yes No

Are you currently taking medication for Type 2 diabetes? *

Yes No

Is there a family history of thyroid cancer or multiple endocrine neoplasia? *

Yes No Not Sure

Step 5 of 6

Your Body & Goals

Help us understand where you are and where you want to be.

Current Weight (lbs) *

Height (ft) *

Height (in)

Goal Weight (lbs) *

How would you describe your current activity level? *

Minimally Active Mostly sedentary, limited exercise Moderately Active Some exercise, 2-3 times per week Very Active Regular exercise, 4+ times per week

Step 6 of 6

Almost Done

One last question, then we'll review your information.

How committed are you to achieving your weight loss goals?

1 7 10

10 = Very Committed

Assessment Submitted

Thank you for completing your eligibility assessment. Our team will review your information and a licensed physician will reach out within 1-2 business days.

Expect to hear from us within 1-2 business days

Check your email for a confirmation

Questions? Email info@mwclinical.com

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