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5Consent

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GLP-1 program — built just for you

It’s not magic - it’s the power of metabolic science. GLP-1 medications replicate natural hormones that control appetite and blood sugar, helping to enhance metabolism and curb cravings.

We know that successful weight loss isn’t about willpower - it’s about consistency. With a simple, once-weekly GLP-1 treatment designed just for you, you could lose up to 20% of your body weight.

Personalized weight loss plans from licensed experts.

GLP-1 Eligibility Quiz

What is your age?*

Are you currently taking any GLP-1 medications?*

Yes

Are you currently pregnant, breastfeeding, or planning to become pregnant within the next 2 months?*

Yes

Personal Information

Confirm that everything you’ve shared is accurate before submitting your form.

Please upload a government-issued form of ID*

Passport, etc. — ensure your full name and photo are easily visible.

Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB.

Name*

Shipping Address*

Email*

Phone*

DOB*

Please attest to the following confirming that all information you have provided to us is true and complete. If you do not agree, you may not submit this form.*

I confirm that I am the patient completing this intake form and have reviewed all questions carefully. I attest that my answers are true, accurate, and complete to the best of my knowledge. I understand the importance of providing my doctor with complete and accurate health information for my care.

I agree and consent

I do not agree

Payment Information

Card Detail

Complete Checkout to Submit Your GLP-1 Request

Your intake is not submitted until your payment information is entered and you click “Submit Intake & Complete Checkout”.

Enter your card to submit your request for provider review. Your GLP-1 plan cannot be reviewed, approved, or shipped until checkout is complete.

Medication: Personalized GLP-1 Medication

Delivery Plan: Monthly Plan

Shipping: FREE

Monthly Price: $254/mo

Total : $254

Today’s checkout amount is $254. If a provider recommends a different medication, dose, or pharmacy option that changes your price, we will contact you before any change is processed.

Only 22 Discounts left. Yours is reserved for minutes.

Prescribed & shipped within 48 hours.

Unlimited Doctor calls 7 days a week.

Promo Code

Yes

I agree to the CareValidate Inc. Terms and Conditions , Privacy Policy , Refund Policy , and that my card will be held on file. I agree that a $254 charge billed as will appear on my card statement at the time of service. Today’s checkout amount is $254. If a provider recommends a different medication, dose, or pharmacy option that changes your price, we will contact you before any change is processed.

See if GLP-1 is right for you

GLP-1 program — built just for you

GLP-1 Eligibility Quiz

Your weight loss goals

Your medical history

Current & past conditions

Personal Information

Payment Information

Complete Checkout to Submit Your GLP-1 Request