Qualification

Which state do you live in?(Required)

Arizona

California

Colorado

Missouri

New Mexico

New York

Are you here to get evaluated for weight loss?(Required)

Yes

What is your gender at birth?(Required)

This will help us understand your body complexity so we can assess you better.

Female

Male

Other

Ok, let's talk about numbers. How tall are you?

Feet(Required)

Please enter a number from 4 to 8.

Inches(Required)

Please enter a number from 1 to 11.

How much do you weigh?(Required)

This helps us calculate your BMI. BMI is one factor that we use to determine your weight care path, so it's important to be as accurate as possible.

Please enter a number from 0 to 700.

What goals are you looking to accomplish?(Required)

Choose all options that apply

Lose weight

Improve general health

Look better

Improve confidence

Improve energy

Just few more questions

What have you tried in the past?(Required)

Choose all options that apply

Exercise

Dieting

Weight loss supplements

Intermittent fasting

Medical weight loss program

What is your date of birth?(Required)

Our bodies and needs change with age (think hormones), so we'll need to know when you were born.

Month

Day

Year

What is your email?(Required)

Consent(Required)

By checking here.. You agree to receive doctor correspondence, transactional and/or marketing messaging from LivewellMD, to the email address that you provided above.

What is your phone number?(Required)

Please enter a valid ten-digit phone number. The number cannot start with zero or one.

Can we also send you text messages about your prescription including tracking information and refill information?(Required)

Yes

Consent(Required)

By checking this box, I also consent by electronic signature to receive phone calls and/or SMS text messages at the phone number(s) above, including my wireless number if provided. I understand these calls may be generated using an automated technology, pre-recorded voices and that data rates may apply. I understand that my consent is not required to buy goods/services and I may opt out at any time to avoid receiving calls or SMS text messages.

You're getting closer to your weight loss goals

Name(Required)

First Last

Shipping Address(Required)

Where would you like us to ship your medication?

Street Address Address Line 2 City State ZIP Code

Comments

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