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Preliminary
Health
Details
Eligibility
Step 1: Let's Get Started!
We're excited to help you start your weight loss journey!
First, let’s calculate your BMI
What is your height and weight?
Your Height (Feet)
Feet
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Your Height (Inches)
Inches
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Your Weight (in lbs)
Your BMI:
0.00
Our doctors can only prescribe if your BMI is 22 or higher.
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Step 2: Set Your Weight Loss Goal
Your BMI is
29.53
—great! Now, set your goal weight so we can create your plan.
What is your goal weight?
Please input goal weight.
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Step 3: Let’s Get to Know You
Sharing a few details will help us personalize your experience.
Full Name
Email Address
Would you like updates on your treatment, prescriptions, and progress?
Yes
Yes
Phone Number
Send me text updates about my prescription and tracking?
By checking the box below you agree to receive text messages in regards to the customer care services provided to you by Silhouette MD. This will be supplementary to other methods of communications about your services and is not a requirement in order for you to receive the services. Message and data rates may apply. You can always text STOP to discontinue receiving messages, and START to resubscribe.
Yes
No
Yes
No
Yes
No
Please input customer info.
Phone number incorrect format.
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Step 4: Your Location
To help us match you with a licensed provider in your area and deliver your prescription safely:
Street Address
City
State
--
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Maine
Maryland
Massachusetts
Michigan
Minnesota
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Select State
ZIP Code
Please input address info.
Zipcode incorrect.
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Step 5: Verify Age & Gender
You must be at least 18 years old to participate.
What is your gender?
This helps us understand your body and hormones for a better assessment.
Male
Male
Female
Female
Please select gender.
Date of Birth
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
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Year
You must be at least 18 years old and not older than 74 years old .
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Step 6: Your Weight Loss History
Tell us about your experience so we can guide you better.
Are you exploring medical weight loss options?
Yes
No
Please choose answer.
Have you tried structured weight loss programs before (e.g., diet, exercise, lifestyle changes)?
Yes
Please include any relevant details here
No, this is my first time
Please choose answer.
Please enter description.
Have you had any bariatric (weight loss) surgery in the past?
Yes
Please include date range and type of surgery below
No
Please choose answer.
Please enter description.
Are you willing to make dietary changes to support your weight loss?
Yes
No (This program requires dietary changes.)
Please choose answer.
Are you open to increasing your physical activity as part of your treatment?
Yes
No (Physical activity is an essential part of this program.)
Please choose answer.
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Step 7: Your Current Medications & Medical History
This helps us create the safest, best plan for you.
Are you currently taking any prescription medications for weight loss?
None
Wegovy/Zepbound/Mounjaro/Ozempic/Trulicity/Saxenda
Compounded Semaglutide
Other (Please specify below)
If applicable: Please provide medication name, dosage, and last use date.
Please choose answer.
Please enter description.
Please list weight loss medication(s) name, dose, frequency, timeline
Please provide weight loss medication(s) name, dose, frequency, timeline
Starting weight (lbs)
Current weight (lbs)
Please enter description.
Will you only use this platform for weight loss meds?
Yes
No
Please choose answer.
When was your last dose?
0-5 days
6-10 days
11-14 days
2-4 weeks ago
> 4 weeks ago
I acknowledge that I will need to restart at the lowest dose
Please choose answer.
Restart at the lowest dose is required
Please include date range, name, dose, and frequency below
Please include date range, name, dose, and frequency below
Please enter description.
Do you have any known medication allergies?
Yes
Please list the allergy-causing medication name, dose, and frequency
No
Please choose answer.
Please enter description.
Are you taking any other medications?
Warfarin
Coumadin
Jantoven
Insulin
Other
None
Please choose answer.
Please list the medication name, dose, and frequency
Please enter description.
When was your last in-person medical check-up?
Less than a year ago
1-2 years ago
More than 2 years ago
Please choose answer.
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Step 8: Health Conditions & Lab Tests
Let us know about your recent tests and any health conditions
Have you had lab tests in the last 6 months?
Yes
No, not at this time
Please choose answer.
Please enter description.
Do you know your current blood pressure?
< 120/80 (Normal)
120-129/<80 (Elevated)
130-139/80-89 (High Stage 1)
>= 140/90 (High Stage 2)
Not sure
Please choose answer.
What is your resting heart rate?
60–100 bpm (Normal)
Below 60 bpm
Above 100 bpm
Not sure
Please choose answer.
Do you have any of the following health conditions?
(Check all that apply)
Currently or possibly pregnant, or actively trying to become pregnant
Breastfeeding or bottle-feeding with breastmilk
End-stage kidney disease (on or about to be on dialysis)
End-stage liver disease (cirrhosis)
Current or prior eating disorder
Current suicidal thoughts and/or prior suicide attempt
Active cancer diagnosis, treatment, or remission < 5 years
(Excludes non-melanoma skin cancer cured by excision)
History of organ transplant and on anti-rejection meds
Severe gastrointestinal condition (e.g., gastroparesis, blockage)
Current diagnosis/treatment for alcohol, opioid, or substance use disorder
None of the above
Please choose answer.
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Step 9: Important Health Considerations
Your safety is our priority. Please review the following carefully and let us know if any apply to you
(these may disqualify you from treatment):
Type 2 diabetes (on insulin)
Type 1 diabetes
Diabetic retinopathy (diabetic eye disease), damage to the optic nerve from trauma or reduced blood flow, or blindness
Use of the blood thinner warfarin (Coumadin/Jantoven)
Pancreatitis (history or current)
Gave birth within last 6 months
Inflammatory bowel disease (Crohn’s, ulcerative colitis)
Personal/family history of thyroid cancer, MTC, MEN2
Gallbladder disease
Seizures
Heart attack or stroke in the past 12 months
Glaucoma
Gout
Depression
Head injury
Brain/spinal tumor or infection
Low sodium
Kidney disease
Elevated resting heart rate (tachycardia)
QT prolongation or other arrhythmias
Congestive heart failure
Hospitalization in past year
Human immunodeficiency virus (HIV)
Constipation
Polycystic Ovarian Syndrome (PCOS)
Hyperemesis gravidarum (nausea/vomiting in pregnancy)
None of the above
Please choose answer.
Do any of the following weight-related medical conditions apply to you?
Hypertension
Obstructive Sleep Apnea
Prediabetes
Type 2 diabetes (not on insulin)
High Cholesterol or Triglycerides
Acid Reflux
Asthma/Reactive Airway Disease
Urinary Stress Incontinence
Polycystic Ovarian Syndrome (PCOS)
Clinically Proven Low Testosterone
Osteoarthritis
Heart attack or stroke in the past 24 months
Congestive Heat Failure
Liver Disease (inc. Fatty Liver)
None of the above
Please choose answer.
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Step 10: Final Details Before We Review
Just a few more things before we confirm your eligibility.
Has your weight change in the last 12 months?
Lost a significant Amount
Lost a little
Stayed about the same
Gained a little
Gained a significant amount
Please choose answer.
Are you diagnosed with prediabetes or Type 2 Diabetes?
Yes
What was your most recent fasting glucose value?
What was your most recent hemoglobin A1c (HbA1c) value?
No
Please choose answer.
Please enter description.
Based on your specific medical history and lifestyle, are you concerned about any of the following?
Muscle loss on GLP-1/GIP
Inability or unwillingness to self-inject
Concern about side effects (nausea, vomiting)
Aging/longevity
Mental clarity
Low energy
Hormonal regulation / menstrual cycle
Sleep quality
None of the above
Please choose answer.
Is there anything you'd like your clinician to know before treatment?
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Step 11: ID Verification & Consent
To keep your info secure, we need a quick verification.
Please upload a valid photo ID for verification.
Take a picture
Upload file
Enter your full legal name as a signature.
Please enter full legal name.
By checking this box, I confirm that my information is accurate and consent to evaluation.
I acknowledge I have read the
Telehealth Consent Form
and give my informed consent to telehealth care.
Please check agree before go to next step.
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Final Step: Review & Eligibility Confirmation
Here’s a summary of your details:
BMI:
29.53
Current Weight:
200
lbs
Goal Weight:
155
lbs within 15 weeks
Estimated Success Rate:
94% chance of positive results
Ready to get started?
CHECK ELIGIBILITY
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