✨ FDA-Approved Medications

Start Your GLP-1 Weight Loss Journey

Get matched with a licensed provider for medically supervised semaglutide or tirzepatide. Results in weeks, not months.

HIPAA Compliant

Licensed Providers

No Hidden Fees

Patient Intake Form

Complete this quick form to check your eligibility. Takes ~2 minutes.

First Name *

First name is required

Last Name *

Last name is required

Email *

Valid email is required

Phone *

Phone number is required

Current Weight (lbs) *

Enter your current weight

Goal Weight (lbs) *

Enter your goal weight

Medical History *

Select any conditions that apply:

Diabetes

Heart Disease

Thyroid Disorder

None of the Above

Please select at least one option

Current Medications

Do you have health insurance? *

Yes

Please select an option

You're In! 🎉

A licensed provider will review your information and reach out within 24 hours to discuss your treatment options.

Check your email and phone for next steps.

This form does not constitute medical advice or a prescription. All treatments are prescribed by independently licensed healthcare providers after a telehealth consultation. Individual results vary. TeleHealth Leads connects patients with licensed clinics — we are not a healthcare provider. By submitting, you agree to be contacted by phone, email, or SMS.