Intake Form

Let's start with some basic information

We do everything on-line so your privacy is maintained completely. Simply fill out the short form and if necessary we'll contact you to arrange a consultation via zoom. The medication is then mailed to you. Starting your weight loss journey is as easy as opening a package.

Please note; We have a telemedicine service available if necessary. Call 702 343 3342 for more information

(All fields; except address 2, are required)

Where do you live?

We will use this address to mail you the product. Please check it carefully

Finally, some basic medical info

This information will help us decide if you are eligible for the products