Dynamic Life Online Prescription for Weight Loss

Take just 3-5 minutes to answer a few important questions that will assist your physician in determining your tailored once per week Injectable Semaglutide weight loss program.

Now any dose just $199 per month

Any dose | 100% Satisfaction guaranteed | Cancel anytime | No hidden fees | No contracts

Additional terms apply

Height and Weight

Feet and inches

Pounds

Goal

Prescription Information

First

Last

Must be 18-75 years old Example: mm.dd.yyyy

Account information

What's the best way for the Doctor to reach you if they have additional questions?

Important: Use ONLY your own phone number and email.

Use only your own email

Use only your own phone number

I am not using my friend or family members email. I Consent to Receive SMS Notifications contains your health information(Possible PHI), Alerts & Occasional Marketing Communication from Dynamic Life. Message frequency varies. Message & data rates may apply. Text HELP to 1 888-346-9959 for assistance. You can reply STOP to unsubscribe at any time.

Semaglutide GLP-1 Use

Do you use GLP-1's?

Oral Semaglutide

What date did you last take semaglutide lozenges?

Semaglutide Injections

What date did you last take semaglutide injections?

Existing Prescription Upload

Already have a prescription? Upload/Send it here.

Please include to allow your provider to start you at your desired dose

Gender

Female

Male

Pregnancy

Are you pregnant?

Yes

Last Menstrual Date

When was your last Menstrual Date?

If no recent menstrual date

I am postmenopausal

I have had a hysterectomy

I am pregnant or breastfeeding

I use hormonal birth control that suppresses my cycle

I have a health condition that affects my menstrual cycle (please specify below)

Other reason

No menstrual cycle other reason

Tobacco

Do you use tobacco?

Yes

Cancer History

Do you have a history of cancer?

Yes

Thyroid Cancer History

Do you have a history of medullary thyroid carcinoma?

Yes

Family Cancer History

Does your family have a history of cancer?

Yes

Diabetic Ketoacidosis

Do you have diabetic ketoacidosis?

Yes

Diabetes

Do you have diabetes?

Yes

Allergies or Sensitivities

Do you have any known allergies or hypersensitivities to medications, vitamins, or supplements?

Yes

Allergies or sensitivities explanation

Do you have any known allergies or hypersensitivities to medications, vitamins, or supplements explanation

Medications and Supplements

Are you currently taking any supplements or medications?

Yes

Supplements or medications explanation

Surgical Procedures

Have you had any surgical procedures?

Yes

Have you had any surgical procedures explanation

Physician Care

Are you seeing a physician?

Yes

Questions

Do you have any questions?

Side Effects

Common Side Effects:

I understand that common side effects may include nausea, vomiting, diarrhea, abdominal pain, and constipation.

Serious Side Effects: Visit drugs.com here for more information.

I understand that Semaglutide may cause serious side effects, including:

Hypoglycemia (low blood sugar): Especially if taken with other diabetes medications. I understand that I may only use Semaglutide if my doctor who is monitoring my diabetes is fully aware of my use. It is 100% my responsibility to communicate my use of Semaglutide and ensure my doctor agrees and monitors it as well.
Pancreatitis: Severe stomach pain that does not go away, with or without vomiting.
Gallbladder Problems: Pain in the upper abdomen, fever, yellowing of the skin or eyes (jaundice), or clay-colored stools.
Kidney Issues: Worsening kidney function, especially in patients with pre-existing kidney problems.

Thyroid Tumors:

I understand that Semaglutide has been associated with thyroid tumors in animal studies, and it is unknown if it causes thyroid tumors or thyroid cancer in humans.

Important Considerations:

I understand that I should not use Semaglutide if I have a personal or family history of Medullary Thyroid Carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
I understand that I must consult my general in-person healthcare provider before starting Semaglutide, especially if I am pregnant, planning to become pregnant, or breastfeeding.

Action Steps:

I agree to and understand that I must contact my healthcare provider promptly if I experience any side effects or have concerns while taking semaglutide.

Summary:

I agree to inform my primary care doctor about my Semaglutide treatment, as well as any other doctors I am seeing. I will also get blood tests through my own doctor at their recommendation as needed. Please call or text us at if you have any questions or are unclear about the instructions.

Yes, I agree

No, I do not agree

Learn more at drugs.com

ID Upload

Please submit a photo of your ID

Acknowledgement

I consent to telehealth evaluation and potential semaglutide treatment; acknowledge risks/contraindications (incl. MTC/MEN2); understand off-label/compounded status; accept HIPAA privacy and electronic communication risks; authorize phone/text/email contact with opt-out; and accept my responsibilities. To the extent allowed by law, I acknowledge the risk statements in the terms and conditions and above and sign voluntarily.

Yes, I agree

No, I do not agree

Signature

Add your electronic signature.

Clear

Mobile users: Use finger to sign

Shipping Address

Eligibility health intake:

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