To begin, please provide your email address:

Email address *

I consent to receive marketing and communications from ActiveMD.

Tell us about your goals. *

Lose a handful of stubborn lbs (fewer than 20lbs)
Lose a significant amount of weight (20lbs or more)
Maintain my weight loss. I have already lost most of the weight I needed to lose but have struggled to keep it off in the past
Improve my heart health. or other underlying medical conditions I believe GLP-1 medications help with
Other goal not listed here

Please enter your height.

Height (ft) *

Height (in) *

Please enter your weight.

Weight (lbs) *

BMI *

Gender *

Birth Date *

Good News! It appears as though you might be a perfect candidate for GLP-1 medication. We need to gather a little more info to confirm.

Based on the information you provided, you are not eligible to be prescribed GLP-1 medications. If you believe some of the information you provided was inaccurate, you may start over.

What weight loss initiatives have you tried in the past? (Select all that apply) *

Exercise
Dieting
Weight-loss Supplements
Intermittent Fasting
Other GLP1's
Food intake ie: Jenny Craig, Weight Watchers, Hello Fresh, etc.
Surgery
Other

Great! So you are already somewhat familiar with the benefits of GLP-1 medications. Which of the following medications have you used? *

Compounded Semaglutide
Compounded Tirzepatide
Ozempic, Wegovy
Mounjaro, Zepbound
Rybelsus
Other

What was the approximate date of your last dose? *

How many mg was your last dose? *

Please upload a copy of your current prescription: If you do not have a digital copy of your prescription, it is acceptable to upload an image of you medication label. *

Choose file or drag here

Supported format: JPG, JPEG, PNG, GIF, SVG.

temp-for-74210-file2-2_

Are you currently taking any medications? Including Prescription, Over-The-Counter (OTC), and Supplements *

Please list all medications you are currently taking *

List any surgeries you have had in the past: *

If you haven’t had any surgeries, type N/A

Do you currently take any of the following medications? *

DPP-4 Inhibitors such as Sitagliptin and Saxagliptin
Sulfonylureas such as (but not limited to) Glipizide
Insulin
Warfarin (also called Jantoven or Coumadin)
Meglitinides such as Repaglinide or Nateglinide
Diuretics such as (but not limited to) Furosemide (Lasix), Bumetanide (Bumex) Hydrochlorothiazide/HCTZ
Selective Serotonin Reuptake Inhibitor (SSRI) such as (but not limited to) Citalopram (Celexa), Fluoxetine (Prozac), Escitalopram (Lexapro)
I don't take any of these medications

Great News! Based on the information you provided, it appears you will qualify for your GLP-1 Prescription. Let's gather some final information so we can submit your completed application for approval.

Please select your state *

Awesome! Your state allows you to have prescription medications approved and prescribed without the need to be seen by your doctor! Instead, one of our providers, who is licensed in your state, will review the information on the medical intake form you have already completed and approve your prescription without a virtual appointment. They will then send your prescription to our pharmacy network to be filled and cold shipped overnight directly to your preferred address. It's really that simple! However, if you would still prefer to speak to one of our providers, you are absolutely able to do so by selecting either video visit or phone visit below. If you choose to have a phone call or a video visit with the provider your next step will be to schedule the call based on their availability. If you choose to get approved based on our provider's review of your medical intake form information, there is no need to schedule an appointment and your prescription, if approved, will be written and sent to the pharmacy for processing within 24hrs.

Which type of consultation would you prefer? *

Awesome! In your state*, prescription approval requires the first medical consultation to be either a phone or video call rather than being reviewed electronically by our ActiveMD doctor. Please select the option below and you will be contacted after submission to schedule your phone or video call with one of our providers. Once your consultation is complete and you are approved, they will then send your prescription to our pharmacy network to be filled and cold shipped overnight directly to your preferred address. It's really that simple!

*States requiring phone or video calls include: AK, AL, LA, MN, MS, ND, NJ, OR, RI, SC, UT, VA, WA, WV

Which type of consultation would you prefer? *

Video Call
Phone Call

Please upload a government issued form of ID (Driver's License, Passport, etc). Please be sure that your full name and photo are easily visible.) *

Choose file or drag here

Supported format: JPG, JPEG, PNG, GIF, SVG.

temp-for-74210-file2-1_

Phone Number *

Cart Products

Perfect! Let's finish up with your shipment and payment info. We gather your payment details so that once approved, your prescription is automatically routed to our pharmacy, filled and shipped to you. Once approved, there will be nothing else you will need to do other than receive your prescription and be on your way to a healthier new you!

Are you an Echelon® member? *

Please enter the email associated to your Echelon® membership. *

Patient Intake Form

To begin, please provide your email address:

Please enter your height.

Please enter your weight.

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