Weight Loss Treatment Intake Δ Step 1 of 14 7% NameThis field is for validation purposes and should be left unchanged.Which weight loss medication would you like?(Required) Semaglutide Tirzepatide How often would you like to be billed?(Required) Monthly Every 3 Months What's your weight loss goal?(Required) Up to 20 lbs 21 to 50 lbs 50+ lbs Maintain my weight and tone up Undecided What is your primary reason for making a change?(Required) To increase my longevity To improve my physical appearance To reduce my health risks To enhance my mental well-being Unsure We can support you in all of these areas, but please select the one that matters most to you right now: Have you taken a GLP-1 medication in the past 2 months?(Required) No, I have not Yes, I have recently taken a GLP-1 medication Examples: Ozempic, Wegovy, Zepbound, or Mounjaro Are you currently taking any medications?(Required) Yes No If yes, please list each medication along with the name, dosage, and frequency.Please include name, dose, and frequency of all your medications Current Height (inches)(Required)Current Weight (lbs)(Required)Important information about this productRead the following for more information about this product and its potential side effects.BMI ConsentWeight loss medications are traditionally prescribed for individuals with a BMI of 30 or higher, or for those who are overweight with related health conditions. Prescribing these medications for individuals with a BMI between 27–29, without an associated condition, is considered "off-label" use. "Off-label" means a medication is being prescribed in a way that differs from its original FDA-approved labeling, such as for a different purpose, dosage, or patient group. While medications are carefully tested for specific uses before approval, healthcare providers may also find—through clinical experience and research—that they can be safe and effective for other situations, including weight management.If you choose to move forward with this off-label use, it's important to follow the prescribed plan closely and keep us informed of any concerns or side effects. Our team is here to answer your questions and support you throughout your treatment.BMI Acknowledgment(Required) By checking this box, you acknowledge the above information What is your gender?(Required) Male Female What is your date of birth?(Required) MM slash DD slash YYYY What is your phone number?(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code SMS ConsentApollo Vital Health may use your phone number to send you:Care and prescription-related updates – such as appointment reminders, treatment notifications, and pharmacy access updates.Service information and offers – including account updates, program availability, and promotional offers. Are you breastfeeding, pregnant, or planning to become pregnant soon?(Required) No Yes Pregnancy and Breastfeeding PrecautionsWeight loss medications may pose a risk to a developing fetus if pregnancy occurs while taking them. Because these medications can reduce the effectiveness of oral contraceptives ("the pill"), oral contraception alone is not considered sufficient. For reliable birth control, our providers recommend non-oral methods such as condoms, an intrauterine device (IUD), or an implant.FDA guidance:During the first month after starting therapy, and for the first month after each dose escalation, continue using oral contraception and discuss additional protective measures with your provider.Alternatively, consider switching to a non-oral contraceptive method (e.g., IUD or implant) before initiating treatment.After discontinuing the medication, a backup method (such as condoms) should be used for two months to ensure the drug is fully cleared from your system before attempting pregnancy.These medications are also not considered safe during breastfeeding. If you are breastfeeding, speak with your healthcare provider about alternative weight management options.Pregnancy/Breastfeeding Acknowledgment(Required) By checking this box, you acknowledge the above information Are you currently managing your weight?(Required) Yes, I am actively managing it Yes, I am somewhat managing it No, I am not managing it How active are you?(Required) Sedentary (I don't exercise) Lightly active Moderately active Vigorous (very active) Do any of these apply to you? None of these apply Hypertension (high blood pressure) Sleep apnea Osteoarthritis or Mobility issues impacted by body weight Gastroesophageal reflux disease (GERD) related to body weight Polycystic Ovary Syndrome with insulin resistance Liver disease or conditions like NAFLD Heart disease or conditions that affect the heart Metabolic Syndrome Chronic Kidney Disease Stage 3 or greater Syndrome of Inappropriate Antidiuretic hormone Hypothyroidism, Hyperthyroidism, or Thyroid Issues Type 2 Diabetes or Prediabetes Do any of these apply to you? None of the below Gallbladder disease or past removal of your gallbladder Gastroparesis High cholesterol or triglycerides Pancreatic cancer or Pancreatitis Type 1 Diabetes, Insulin-dependent diabetes, and/or Hypoglycemia Personal or family history of thyroid cancer Personal or family history of Multiple Endocrine Neoplasia (MEN-2) syndrome Anorexia or bulimia Current symptomatic gallstones Do you have any drug or food allergies?(Required) No Yes Please list your allergies If you qualify for the program, which benefits are important to you? Maintenance of muscle mass Avoiding injections (oral options) Managing side effects such as nausea/vomiting Assistance with healthy aging and longevity (support of cellular/DNA health and immune function) Assistance with improving cognitive function and mental clarity Assistance with maintaining energy levels Assistance with regulating menstrual and hormonal health Assistance with improving sleep quality I'm not sure; I'd like to discuss formulation options with a clinician during a live virtual consult We take your specific situation into account while determining your medication formulation. Email Address(Required) Name(Required) First Last Create Password(Required) Enter Password Confirm Password Terms and Consent(Required) I agree to AVH terms and privacy policy and consent to telehealthBy checking this box, you agree to our Terms of Service, Privacy Policy, and consent to receive telehealth services.
