What is your height and weight?
Are you male or female?
What is your date of birth?
Health Questions 1
Do any of these apply to you?
Select all that apply
Health Questions 2
Do any of these apply to you?
Select all that apply
Within the last 3 months, have you taken opiate pain medications and/or opiate-based street drugs?
No
Yes
Have you had prior weight loss surgeries?
No
Yes
Do you currently take any prescription medication?
No
Yes
What is your blood pressure range?
< 120/80
Normal
120 - 129/<80
Elevated
130 - 139/80-89
Hypertension Stage 1
≥ 140/90
Hypertension Stage 2
*For your safety, this answer may disqualify you from a prescription
What is your average resting heart rate?
<60 beats per minute
Slow
60 - 100 beats per minute
Normal
101 - 110 beats per minute
Slightly Fast
>110 beats per minute
Fast
When nothing else worked… Wellvera did
Are you ready for your next chapter?
With medication, you'll lose
3.75 to 5 pounds per week.
It will take about 13.33 weeks to reach your
goal weight of 200.
How is that pace for you?
That works for me
I want it faster
That's too fast
Perfect!
Have you taken medication for weight loss within the past 4 weeks?
Yes, I've taken GLP-1 medication
Yes, I've taken a different medication for weight loss
No
Great! You have experience with GLP-1.
Please list the name, dose, and frequency of your GLP-1 medication.
When was your last dose of medication?
0-5 days
6-10 days
11-14 days
More than 2 weeks ago but within the last 4 weeks
More than 4 weeks ago
What was your starting weight in pounds?
Please take or upload a photo of your GLP-1 medication
If you are requesting a prescription for your current or higher dose, this is important. If you don't have a photo available, you can skip this.
Do you agree to only obtain weight loss medication through this program moving forward?
It's important not to "stack" weight loss medications.
No
Yes
Great! You have experience with weight loss medication.
Do you agree to only obtain weight loss medication through this program moving forward?
It's important not to "stack" weight loss medications
No
Yes
How about weight loss programs?
Have you ever tried to lose weight in a weight management program (Jenny Craig, Weight Watches, etc)?
Yes
No
How about weight loss programs?
Have you ever tried to lose weight in a weight management program (Jenny Craig, Weight Watches, etc)?
Yes
No
Your needs are unique, and your
medicine should be too!
Your GLP-1 medication is personalized to your
specific needs
Please select the following options that you are
interested in.
interested in.
Wellvera medical providers review every form within 24 hours
Do you have any further information which you would like our medical team to know?
Yes
No
Wellvera
GLP-1 Treatment
Assessment Complete
Ready for Review
Assessment Complete
Congratulations! You're a strong candidate for medical weight loss treatment.
Your Medical Review
Success Probability
94%
You are a strong candidate for medical
weight loss treatment.
Let's proceed to check your eligibility.
First Name
Last Name
What state will your medication be shipped to?
Your information is never shared and
is protected by HIPAA.
is protected by HIPAA.
, how can you be reached if
necessary?
Our medical teams and pharmacy use email and text for
patient communication.
patient communication.
Email
Phone Number
I understand that my information is never shared, is protected by HIPAA and agree to the terms and privacy policies and to be contacted as necessary by Wellvera and its medical partners and can opt-out at anytime.
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