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Personalized Protocol for Product Name
Complete this brief assessment to ensure your treatment is safe, effective, and tailored to your goals.
What are your main reasons for using a GLP-1 medication?
Select up to 3 options that best match your goals.
Do any of the following apply to you?
Which of the following have you tried for maintaining healthy weight in the past?
Have you taken a GLP-1 medication before?
Which have you tried?
Are you currently taking either Semaglutide or Tirzepatide?
What was your most recent dose in milligrams per week (mg/wk)?
Which is the GLP-1 you've taken most recently?
When did you last take it?
What was your most recent Semaglutide weekly dose?
What was your most recent Tirzepatide weekly dose?
For this shipment:
Since you have been off of the medication for over 1 month, it's not recommended to restart immediately at your previous dose.
However, you'll be provided enough medication to titrate up to your previous weekly dose in the first month with this shipment, following safe titration guidelines.
If you resume at your previous dose immediately, you may experience heavier side effects such as nausea, vomiting, and digestive discomfort.
Please review your treatment details below
Your Prescription
Bottle Size
20mg
Weekly Dose
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Based on your answers, your Tirzepatide Subscription will start at a dose of .
In order to do this safely, we need to verify your recent dosing and/or treatment history from the past 8 weeks.
• Already a Levers Tirzepatide patient?
We already have your order history and will verify with that.
• New to Tirzepatide with Levers?
You'll need to provide a prescription or supporting documentation of your most recent dose before we can confirm your first shipment.
📋 Briefly describe your recent Tirzepatide treatment history:
Proof of dosing upload
Please upload a dated prescription, receipt or other supporting documentation confirming your most recent Tirzepatide dose.
Our clinical team will review this information and will provide the your first month dosing accordingly.
What are your body composition goals with the support of GLP-1 medication?
WHAT IS YOUR DESIRED TIMEFRAME FOR ACHIEVING YOUR GOALS?
Are you willing to make lifestyle changes such as improving nutrition, exercise, and sleep while taking GLP-1 medication?
Are you willing to possibly experience side effects associated with this medication (e.g., nausea, fullness, constipation)?
Do you have Gallbladder disease or removal?
Have you ever been diagnosed with an eating disorder such as anorexia or bulimia, or experienced behaviors such as purging that have not been fully resolved (not including normal dieting or fasting)?
Consent
Do you confirm that:
1) You will inform your other healthcare providers that you are starting this medication, and continue regular health check-ups with your primary provider?
2) The information is the form is complete and accurate?
Safety Check
Please review the following.
YOU'RE ALMOST DONE
You're one step away from completing your intake form but we still need your other products medical intake forms.
- Your responses will be securely stored
- You'll be redirected to complete additional product forms
COMPLETE SUBMISSION
Thank you for completing your medical intake form, to finish the process please click the submit button.
- Your provider will review your medical information within 24 hours
- You'll receive an email confirmation shortly
- Questions? Contact support anytime
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