FIRST TIME QUESTIONNAIRE

First Time Questionnaire Form

Member First Name *

Member Last Name *

Member Date of Birth *

Member Social Security # (9 digits, No dash or Space) — required unless Employer Employee ID + Dependent Number are provided

Member Email *

Member Phone *

Enter at least 10 digits

Member Address Line 1 *

Member Address Line 2

Member City *

Member State *

Member ZIP Code *

Drug Name *

Quantity *

Day Supply *

Weight in Pounds *

Range: 50-800 lbs

Height in Inches *

Range: 36-96 inches (3-8 ft)

BMI (Body Mass Index) *

Do you have Prediabetes, Hypertension, Kidney Disease, Heart Failure or any Cardiovascular diseases? *

Secure submission. Your information is sent securely, and any files you upload are stored privately and available only to authorized reviewers. Please enter only the information needed to review this request.

Please read the following information prior to completing this form.

Please fill out this form to request eligibility for the program. You will not be able to participate in the program or seek reimbursement for GLP-1 drugs without having first completed this form and having been approved.
Submission will be reviewed and you will be notified of a decision within 3 days.
Once you have received approval email, you will be able to start using your credit toward the purchase of GLP-1 drugs.