Form – Thrivvme

Reach your goal weight fast
without restrictive diets.

Please answer the following questions so we can pre-qualify you for medical weight loss.

What is your height?

Current Weight

Goal Weight

Are you male or female?

Male Female

Do any of these apply to you?

Currently/possibly pregnant

Breastfeeding or bottle-feeding

Given birth within 6 months

None of the above

For your safety, medication is not recommended during pregnancy or breastfeeding.

Date of Birth

Taken opiate-based street drugs/meds in the last 3 months?

Yes No

Provide details

Prior weight loss surgeries?

Yes No

Provide details

Do you currently take any prescription medications?

Yes No

Please list medications

What is your blood pressure range?

High Blood Pressure requires monitoring.

What is your average resting heart rate?

Are you ready for your next chapter?

When nothing else worked... MEDVi did!

With medication, you'll lose _ to _ pounds per week.

It will take about _ to reach your goal weight of _ lbs.

How is that pace for you?

That works for me

I want it faster

That's too fast

Perfect!

Losing weight is easier than you think...

Taken medication for weight loss within the past 4 weeks?

Yes, I've taken GLP-1 medication

Yes, a different medication for weight loss

No, not in the past 12 months

Great!
Experience with GLP-1.

List name, dose, frequency

When was your last dose?

Starting weight in pounds

Take/upload photo of medication (Optional)

Agree to only obtain through this program?

Yes No

Great!
Experience with medication.

List name, dose, frequency

Starting weight in lbs

Agree to only obtain weight loss med through this program?

Yes No

How about programs?

Tried weight management programs (Jenny Craig, etc)?

Yes No

Please provide brief details

Looking good! Let's match you with the best medication.

Which is most important to you?

Affordability

Potency

GLP-1 injection or tablet?

I prefer to inject

I prefer a tablet

MEDVi medical providers review every form within 24 hours.

Do you have any further information for our medical team?

Yes No

Provide details here

Please select options you are interested in

Maintaining muscle mass

Prefer not to inject

Managing nausea

Anti-aging/longevity

Cognitive function

Energy levels

Regulating menses

Sleep quality

I’m not sure/discuss with clinician.

Your BMI is _

You plan to go from _ to _ lbs.

It will take about _ to reach your goal.

First Name

Last Name

What state will your medication be shipped to?

Please check and confirm your email address (.con typo detected)

Phone Number

I agree to the Terms of Service and Privacy Policy, and consent to receive marketing SMS/emails.

GLP-1 Consent for Seniors (Required)

Notice

Our first priority is your safety. Based on your answers, we can not pre-qualify you for a prescription.

Reach your goal weight fast without restrictive diets.

Are you ready for your next chapter?

Perfect!

Great! Experience with GLP-1.

Great! Experience with medication.

How about programs?

Looking good! Let's match you with the best medication.

Notice

Reach your goal weight fast
without restrictive diets.

Great!
Experience with GLP-1.

Great!
Experience with medication.