Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.1234567Do any of the following apply to you? * *Currently treated or diagnosed with cancerCrohn’s DiseaseHave an active eating disorderActive gallbladder disorderHad bariatric surgeryHistory of drug or alcohol abuseHistory of pancreatitisHistory of depression or Bi-polarFamily history of thyroid cancerHistory of medullary thyroid cancer or MEN syndromeLiver diseaseKidney DiseasePancreatic insufficiencyRecent Heart AttackAbnormal heart rhythmType 1 diabetesSlowed gastric motility/bowel obstructionAre you now or expecting to become pregnantNone of the aboveThe selected condition does not allow you to get this treatment NextName *FirstLastBirthdate Month/Day/YearMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920I am joining this Vincere Vita program to *Change body compositionTransition to an intermittent fasting lifestyleImprove energy levelsChange eating habitsChange fitness habitsI have a different reasonWhat is your assigned sex at birth? *MaleFemaleDo you identify as that?YesNoPreviousNextDo any of the following apply to you? *I tend to feel fatigued after mealsI excess fat around the waistI crave sweetsI tend to overeatI never feel full and satisfied after a mealnone of the abovePreviousNextWhat is your height? *What is your current weight? *Do you smokeYesNoDo you take any medications, including prescription medications, over-the-counter medication, or recreational drugs? *YesNoPlease provide details *NextDo you have any allergies to medication? *YesNoPlease provide details (copy) *Is there anything else you would like to tell the provider? *YesNoPlease provide details (copy) *PreviousNextPlease upload a picture of your ID * Click or drag a file to this area to upload. Upload a photo of your face. * Click or drag a file to this area to upload. Telemedicine law requires us to verify your identity to access treatment.PreviousNextI agree to billing and cancelation and return policy *I agreeI consent to schedule a Telemedicine consultation, with the option to cancel up to 24 hours in advance. For a no-show, a $30 fee will apply. *I agreeI agree that Vincere Vita find a compounding pharmacy to fulfill my prescription. *I agreeSubmit