Initializing medical intake form...
Welcome to Levers! 🌟
To be approved for your new treatment, please submit this medical history form.
You won't be charged until approved, and your assigned doctor will reach out if questions arise. You'll be notified within 24 hours of submitting.
By continuing, you certify that you have read and consent to our Telehealth Agreement, Terms and Conditions, and Refund Policy.
New Patient Information Required
Since this intake is for someone else, we need to collect their full medical information. Please complete all the following steps with their details.
Let's get started.
Information Mismatch
We noticed a difference between your order information and the details just provided.
Your information will be updated in your order to ensure the correct contact details are programmed.
Who is this intake for?
Please confirm who will be receiving this treatment.
New Contact Confirmed
Your order profile will be updated with these new details to ensure seamless communication with your order.
Third-Party Consent
This medical intake form must be filled out by the person receiving treatment, or an authorized representative.
By continuing, you certify that all information provided is accurate and that you have explicit permission to submit medical data on behalf of this individual.
What state do you live in?
State Restrictions
The following products cannot be shipped to your state due to local regulations.
Continue: Refund restricted items and proceed with eligible products.
Cancel All: Full refund for your entire order.
Body Metrics
Eligibility Confirmed
Based on your metrics, you are eligible for the following requested treatment(s):
Your medical profile qualifies for our weight health protocols. Our providers will review your full history to confirm the best protocol.
Protocol Notice
One or more of your selected products have a specific BMI requirement for safety and efficacy.
Already on GLP-1 therapy or have a unique medical situation?
If you are transferring from another provider or have medical notes to share, you may request a provider review exception.
When is your birthday?
Biological Sex
Pregnancy & Hormonal
Which of these best describes your activity levels?
I participate in strenuous physical activity like running, heavy lifting, or intense aerobic activity 4-7 days a week.
I participate in moderate physical activity like brisk walking, cycling, or yard work for 3-5 days a week.
I engage in light physical activity such as walking or household chores 1-4 days a week.
I don't engage in extra physical activity beyond the needs of meeting my daily schedule.
Which of these best describes your diet?
I regularly consume a balanced diet rich in fruits, vegetables, lean proteins, whole grains, and healthy fats. I rarely eat processed foods or sweets.
I generally eat a balanced diet, but I occasionally consume unhealthy foods or sweets, and/or sometimes alcohol in excess of 3 drinks.
I often eat process foods, fast food, or sweets, and/or my eating habits vary widely day-to-day.
Do you have or have you ever had cancer?
Have you been diagnosed with Diabetes or insulin resistance?
Do you or have you had any cardiovascular diseases?
Do you or have you had any Thyroid Conditions?
Do you have or have you had any auto-immune diseases or conditions?
Have you ever been diagnosed with mental health conditions?
Do you have any neurological disorders?
Do you have any Musculoskeletal Disorders?
Do you have or have you had any Digestive Disorders?
What was your last blood pressure reading?
What was your last total cholesterol reading?
Select any lifestyle factors that currently apply to you:
Family Medical History
Select any conditions that run in your immediate family (parents, siblings):
List any past surgeries and the year they were performed
(Example: Appendectomy – 2018.
Enter “None” if you have not had any surgeries.)
List any medications, supplements, vitamins or over-the-counter products you take regularly
Include dosage if known. Enter “None” if you don’t take any.
Do you have or have you had any other medical conditions not previously mentioned?
Upload Photo ID
Front side only. Please ensure all details are legible.
MUST BE GOVERNMENT-ISSUED ID, NOT A SELFIE, OTHERWISE YOUR PROFILE REVIEW WILL BE HELD UP UNTIL PROPER IDENTIFICATION IS SUBMITTED.
How did you hear about Levers?
You selected --. Please let us know how we were introduced!
If a patient referred you, please let us know their name so that we can thank them!
Intake Almost Done!
Hey! You have already successfully completed this medical history form.
You're all set!
Thank you! Your information has been successfully processed.
Order Refunded
This order has been cancelled and refunded. You will receive your refund within 5-10 business days.
If you believe this was an error or would like to place a new order with different products, please visit our store.
You must complete product-specific medical questions for each treatment in your order.
Please provide details:
Safety Check
Please review the following.