Semaglutide Eligibility Questionnaire

Please answer the 1 minute questionnaire to confirm your eligibility.8 Questions


Start

Do any of the following apply to you?*

Please select the options below that apply to you. If none apply, select “None of the Below”.

None of the belowCurrently pregnantBreastfeedingHypothyroidism / Thyroid Dysfunction

Do any of the following apply to you?*

Please select the options below that apply to you. If none apply, select “None of the Below”.

Option 1Option 2Option 3

Do any of the following apply to you?*

Please select the options below that apply to you. If none apply, select “None of the Below”.

YesNo

Do any of the following apply to you?*

Please select the options below that apply to you. If none apply, select “None of the Below”.

Demo 1Demo 2Demo 3

Do any of the following apply to you?*

Please select the options below that apply to you. If none apply, select “None of the Below”.

Your name

Your email

Subject

Your message (optional)

We’re sorry, you are not eligible.

Certain pre-existing conditions or medical situations do not permit patients to take semaglutide (GLP-1).