Patient Health Assessment | Begin Your GLP-1 Evaluation

Personal Information

Let's start with the basics so we can personalize your experience.

If approved, you'll have the option to enroll in the Grace Care Plan — monthly physician monitoring and automatic refill.

First Name

Last Name

Email Address

Phone Number

Date of Birth

State of Residence

Body Metrics

Your physician uses this information to assess your eligibility and calculate an appropriate starting dose.

Height (ft)

Height (in)

Current Weight (lbs)

Goal Weight (lbs)

Biological Sex

Medical History

Please select any conditions that apply to you. This helps your physician identify the safest, most effective therapy.

Current Medications

List any prescription medications, supplements, or over-the-counter drugs you currently take. Your physician needs this to screen for interactions.

Current Medications (if none, write "None")

Are you currently taking any GLP-1 medications?

Yes — I am currently on a GLP-1 medication No — I am not currently on a GLP-1 medication

Known Drug Allergies (if none, write "None")

Final Step

Select your preferred treatment and confirm your consent to proceed.

Preferred Therapy (your physician makes the final determination)

Semaglutide — GLP-1 · Starting at $299/mo Tirzepatide — GLP-1 + GIP Dual Action · Starting at $349/mo Physician's Recommendation — Let the physician decide what's best for me

What are your primary health goals? (Optional)

Consent & Agreements

I consent to receive telehealth services and understand that physician consultation fees apply regardless of whether I am deemed a candidate for medication. I have read and agree to the Privacy Policy and Terms of Service. I consent to the collection and use of my health information as described. I confirm that all information I have provided is accurate and complete to the best of my knowledge.

Grace Care Plan

Monthly physician monitoring + automatic refill

Physician reviews your progress each month
Medication ships automatically before you run out
Dose adjustments managed by your physician
30-day notice required to cancel or pause

Enroll me in the Grace Care Plan — monthly physician monitoring and automatic refill. I understand cancellation or pause requires 30 days written notice.

By submitting, you acknowledge that a physician will review your assessment. You will be contacted within 1 business day via email. Payment is collected after physician approval only.

Tell Us About Yourself

Personal Information

Body Metrics

Medical History

Current Medications

Final Step