Semaglutide Weight Optimization

Medical Questionnaire

Take just 3-5 minutes to answer a few important questions that will assist your physician in determining your tailored Semaglutide weight loss program

Don't have a code? Text 1-888-503-8488 to get one!

Shipping State

What is your shipping state?

Height and Weight

What is your height and weight?

Height

Semaglutide GLP-1 Use

Are you currently using Semaglutide GLP-1?

Never used Semaglutide

Not used in the last 30 days

Yes, I use Semaglutide Injections

Yes, I use Semaglutide Oral

Lozenges Use (Troches)

What is the date you last took semaglutide lozenges?

What is the last dosage?

Last Dose Taken

How many weeks have you been on your current dose?

Describe your experience with Semaglutide for weight loss, including any side effects, improvements, challenges, or observations you've encountered.

Prescriptions Upload

Transer Existing Prescription: Upload Cop Of Current Prescription

DOB

What is your date of birth?

MM/DD/YYYY | Date of Birth must be the same as on government ID. Minimum Age Requirement of 21 Years of Age and Older

Gender

What is your gender?

Male

Female

Pregnancy

Are you pregnant?

Yes

Last Menstrual Date

When was your last Menstrual Date?

If no recent menstrual date, select from below:

I am postmenopausal

I have had a hysterectomy

I am pregnant or breastfeeding

I use hormonal birth control that suppresses my cycle

I have a health condition that affects my menstrual cycle (please specify below)

Other reason (please specify below)

Tobacco

Do you use tobacco?

Yes

Cancer History

Do you have a history of cancer?

Yes

Thyroid Cancer History

Do you have a history of medullary thyroid cancer?

Yes

Family Cancer History

Does cancer run in your family?

Yes

Diabetic Ketoacidosis

Do you have diabetic ketoacidosis?

Yes

Allergies or Sensativities

Do you have any allergies or sensitivities to medications, foods, or other substances?

Yes

Medications and Supplements

Are you currently taking any medications or supplements

Yes

Surgical Procedures

Have you undergone any surgical procedures before?

Yes

Physician Care

Are you currently under the care of a physician for any other medical conditions?

Yes

Last Note

Please explain if there is anything else we haven't addressed or if you have any further questions, please add them here.

Side Effects

Please review the potential side effects of Semaglutide and check the boxes below to confirm your understanding:

Common Side Effects:

I understand that common side effects may include nausea, vomiting, diarrhea, abdominal pain, and constipation.

Serious Side Effects:

I understand that Semaglutide may cause serious side effects, including:

Hypoglycemia (low blood sugar): Especially if taken with other diabetes medications. I understand that I may only use Semaglutide if my doctor who is monitoring my diabetes is fully aware of my use. It is 100% my responsibility to communicate my use of Semaglutide and ensure my doctor agrees and monitors it as well.
Pancreatitis: Severe stomach pain that does not go away, with or without vomiting.
Gallbladder Problems: Pain in the upper abdomen, fever, yellowing of the skin or eyes (jaundice), or clay-colored stools.
Kidney Issues: Worsening kidney function, especially in patients with pre-existing kidney problems.

Thyroid Tumors:

I understand that Semaglutide has been associated with thyroid tumors in animal studies, and it is unknown if it causes thyroid tumors or thyroid cancer in humans.

Important Considerations:

I understand that I should not use Semaglutide if I have a personal or family history of Medullary Thyroid Carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
I understand that I must consult my general in-person healthcare provider before starting Semaglutide, especially if I am pregnant, planning to become pregnant, or breastfeeding.

Action Steps:

I agree to and understand that I must contact my in-person healthcare provider promptly if I experience any side effects or have concerns while taking semaglutide.

Summary:

I agree to inform my primary care doctor about my Semaglutide treatment, as well as any other doctors I am seeing. I will also get blood tests through my own doctor at their recommendation as needed. Please call or text us at 1-888-503-8488 if you have any questions or are unclear about the instructions.

By continuing you agree to these terms...

Contact Information

What's the best way for the Doctor to reach you if they have additional questions?

Introductory first month price, any dose

$139

Add coupon code NEW for your discount promotion on your first month.

I agree with the terms and condition of JumpstartRx and semaglutide-online.com's Patient Medication Evaluation. I consent to and request to be contacted via the provided channels: press-to-be-transferred auto-call, text message, email, and phone call. Data rates may apply. I understand that I can opt out at any time by emailing [email protected] or calling 1-888-503-8488

Free health intake evaluation: See if you're eligible now

🎉 First time? with JumpstartRx Enter your promo code at checkout.

Semaglutide: SEMANEW → $139 first month then $179 any dose

Tirzepatide: TIRZNEW → $199 first month then $279 any dose

Introductory first month price, any dose

$139

Add coupon code NEW for your discount promotion on your first month.

🎉 First time? Enter your promo code at checkout.

Semaglutide: SEMANEW → $139 first month then $179 any dose

Tirzepatide: TIRZNEW → $199 first month then $279 any dose
What's Next?

Confirm Health Status:

Complete the required health questionnaire to confirm health status, choose your product and purchase

Review & Approval Process:

24-Hour Priority Review: Your application undergoes a fast, priority review within 24 hours, from Monday to Friday

Direct Communication:

If we need more details, we'll reach out via text same day.

Fast Processing:

We send your prescription to the pharmacy within 24 hours on weekdays.

Support:

Text us at 1-888-503-8488 any time, or call between 7am to 7pm daily.

Prepare for Arrival:

Delivered 2-4 business days from today.

Quick Delivery:

Expect your medication to arrive in 3-6 business days. Look for a text message with your tracking information with-in 24 hours on weekdays.

Free health intake evaluation: See if you're eligible now

🎉 First time? with JumpstartRx Enter your promo code at checkout.

Semaglutide: SEMANEW → $139 first month then $179 any dose

Tirzepatide: TIRZNEW → $199 first month then $279 any dose

Introductory first month price, any dose

$139

Add coupon code NEW for your discount promotion on your first month.

🎉 First time? Enter your promo code at checkout.

Semaglutide: SEMANEW → $139 first month then $179 any dose

Tirzepatide: TIRZNEW → $199 first month then $279 any doseWhat's Next?

Confirm Health Status:

Complete the required health questionnaire to confirm health status, choose your product and purchase

Review & Approval Process:

24-Hour Priority Review: Your application undergoes a fast, priority review within 24 hours, from Monday to Friday

Direct Communication:

If we need more details, we'll reach out via text same day.

Fast Processing:

We send your prescription to the pharmacy within 24 hours on weekdays.

Support:

Text us at 1-888-503-8488 any time, or call between 7am to 7pm daily.

Prepare for Arrival:

Delivered 2-4 business days from today.

Quick Delivery:

Expect your medication to arrive in 3-6 business days. Look for a text message with your tracking information with-in 24 hours on weekdays.

Tirzepatide: TIRZNEW → $199 first month then $279 any dose
What's Next?