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Diet Form (Active)

Height (feet)

Height (inches)

Weight (pounds)

Your BMI Score is:

Date of birth

Sex assigned at birth

Are you currently taking or have recently (within the last 12 months) taken a GLP-1 medication?

Yes

No

Do you have a family or personal history of medullary thyroid cancer?

No

Yes

If Female, are you currently pregnant or breastfeeding?

No

Yes

Tell us about yourself

Medication

Semaglutide $249 / Month

Tirzepatide $359 / Month

First Name

Last Name

Email

Address

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Phone/Mobile

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