Please complete this form to determine if you may be a candidate for Tirzepatide treatment. All information will be kept confidential.
Include dosages if known. This helps us identify any potential drug interactions.
Please share any other relevant medical information, allergies, or questions you may have about Tirzepatide treatment.
I understand this program requires an eligibility review and is not guaranteed.*
I confirm that the information I provided is accurate to the best of my knowledge.*
I understand that participation in this program is entirely voluntary, and you are doing so at your own discretion and understanding*
I understand that once the program has been purchased, due to the nature of the product that there is no refund*
