• Thank you for choosing Dollar Dad Club. The following questions will provide important information to your assigned provider so they can properly access your condition and prescribe medication if appropriate.

    The information you are about to provide will be used by a board certified physician licensed in your state to help create a treatment plan for you. Please answer all questions accurately.

    By clicking "Start" you consent to our Telehealth, Privacy Policy and Terms.

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  • Unfortunately we cannot service this condition in your state. Please contact your local physician for assistance.

  • Your state may require a phone or video consultation to complete your treatment. Don't worry! Your doctor will reach out to you if this is the case.

  • Format: (000) 000-0000.
  • Can we also send you text messages about your prescription including tracking information and refill information?*
  • today*
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  • Sorry, you must be over 18 to use this service

  • We require that you provide a recent blood pressure measurement within the last six months.
    Blood pressure should be listed as follows: Systolic (top number) / Diastolic (bottom number)If you are not sure, please go have your blood pressure obtained (often free at your local pharmacy).

  • If you are not sure, please go have your blood pressure obtained (often free at your local pharmacy).

  • Any medical conditions your doctor should know about?*
  • Are you taking any medications?*

  • Note: Many medications have interactions. Your doctor needs to know every medication that you take to help avoiding any harmful interactions.

  • Do you have any allergies or intolerances?
  • Are you here to be evaluated for weight loss?*

  • All responses will be evaluated by a board-certified physician. Medication may be prescribed for appropriate candidates.

  • We're sorry, it looks like you're not in the correct place!

    Perhaps you made a wrong choice? Use the Previous button if you'd like to change your answer.

  • Have you ever attempted to lose weight in a weight management program?*

  • Examples may include caloric restriction through diet, exercise, or behavior modification.

  • Are you willing to reduce your caloric intake alongside medication?*

  • We're sorry that you're not willing to help participate in weight loss through diet restriction.

  • Are you willing to increase your physical activity alongside medication?*

  • We're sorry that you're not willing to help participate in weight loss through physical activity.

  • Are you CURRENTLY taking any PRESCRIPTION medications for weight loss?*

  • Wegovy/Zepbound/Mounjaro/Ozempic/Trulicity/Saxenda

    Please type ALL of the drug information which is found on the label of your CURRENT medication

    1. Name of drug
    2. Concentration (ex: 2.5mg/mL)
    3. How many units you inject every week
    4. What is the date of your last dose?
    5. If you would like to stay at same dose, or be increased?

  • Take a picture of your current prescription/medication:

    • Must include your name on the prescription.
    • You may add pictures later if you cannot provide at this time.
    • Without a picture, your doctor will not consider starting you at a higher dose.
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  • Compounded Semaglutide or Tirzepetide

    Please type ALL of the drug information which is found on the label of your CURRENT medication.

    1. Name of drug
    2. Concentration (ex: 2.5mg/mL)
    3. How many units you inject every week
    4. What is the date of your last dose?
    5. If you would like to stay at same dose, or be increased?

  • Take a picture of your current prescription/medication:

    • Must include your name on the prescription.
    • You may add pictures later if you cannot provide at this time.
    • Without a picture, your doctor will not consider starting you at a higher dose.
  • *
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  • What other medication are you taking for weight loss?

    You answered you take other weight loss medication. Please give the name, dose and date of the medication you are taking.

  • Please uncheck "None at this time" if you have other selections.

  • When was the last time you had an in person medical evaluation?*

  • We want to make sure you have recently been evaluated in person by a healthcare provider.

  • Have you had any lab tests completed within the last 6 months that you would like to share with your doctor?*

  • If you do not, we'll provide you with a lab slip to obtain labs at any lab of your choice over the next month.

  • Your doctor only needs to see cholesterol levels, TSH (thyroid test), Ha1c, and Creatinine (kidney function).

    Any additional labs which you upload will not be reviewed. The doctor who ordered these labs is in charge of interpreting them.

  • *
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  • Do you have any of the following?*

  • These are considered 'co-morbidities' by the American Board of Obesity Medicine. While you may not need to have one of these for treatment, your doctor would like to know.

  • Please uncheck "None of the above" if you have other selections.

  • Do you have any of the following?*
  • Are you sure you have Type 1 Diabetes?*

  • Please tell the doctor:

    1) What kind of bariatric surgery or other GI surgery
    2) What year and month this surgery was performed
    3) Any complications or continued problems you have had

  • Please tell the doctor:

    1) What type of gallbladder problems you are currently having
    2) Has your gallbladder been surgically removed?

  • Please uncheck "NONE of the above" if you have other selections.

  • Does anyone in your family have a history of...*

  • Please uncheck "NONE of the above" if you have other selections.

  • Do you have any of the following?
    If you have any of the following you should not take semaglutide with B12 (cyanocobalamin).

  • Do you have any of the following?*

  • Please uncheck "NONE of the above" if you have other selections.

  • Do you have any of the following?*

  • Please tell the doctor more and include any lab values you may know of such as:

    1. Creatinine (Cr)
    2. Creatinine Clearance (CrCl)
    3. Glomerular filtration rate (GFR)
    4. Or simply describe more about your kidney problems

  • Please uncheck "NONE of the above" if you have other selections.

  • Please read the following about all GLP-1s


    HOW THEY WORK:
    Increasing insulin production from the pancreas.
    Decreasing glucagon release after a meal. Glucagon triggers your liver to store fat.
    Slows gastric emptying, which will make you feel ‘full’.

    BENEFITS:
    GLP-1's have been shown to help with weight reduction when combined with lifestyle medications such as exercise and reduction of caloric intake.

    RISKS:
    Medicines in the GLP family have caused thyroid tumors in lab mice. It is not yet known if they will cause thyroid tumors or medullary thyroid carcinoma (MTC) in people. No studies have confirmed a linkage between GLP-1's and thyroid tumors in humans.

    COMMON SIDE EFFECTS:
    Nausea, constipation, gastroesophageal reflux, diarrhea, fatigue

    RARE SIDE EFFECTS:
    Depression and hair loss.

    YOU SHOULD NOT USE A GLP-1 IF YOU HAVE ANY OF THE FOLLOWING:
    Eating Disorder
    Gallbladder Disease (does not include gallbladder removal/cholecystectomy)
    Severe GI disease (eg: gastroparesis, Crohns, ulcerative colitis)Drug Abuse
    Alcohol Abuse
    Recent Bariatric Surgery
    Chronic pancreatitis, or pancreatitis while taking a GLP-1
    Personal or family history of medullary Thyroid Cancer
    Multiple endocrine neoplasia type 2 syndrome (MEN-2)
    Currently Pregnant (or planning to become pregnant)
    Currently Breastfeeding
    Retinopathy

  • Please read the following about all GLP-1s*
  • Would you like a prescription of nausea medication to be sent to your local pharmacy?*

  • This is not covered thru this program and therefore will be an extra cost, however generally is not an expensive medication.

  • Please review the Florida Bill of Rights for Weight Loss:

    Please click this link: Florida Bill of Rights to view/download.

  •
  • If your treatment made you significantly nauseated or caused other GI side effects would that impact your compliance with treatment and willingness to continue?*
  • Approximately 40% of patients using commercially available GLP-1 treatments experience nausea. Is it important to you to minimize possible nausea and GI side effects during your treatment?*
  • In any prior attempts to lose weight, do you feel you experienced loss of muscle as well?*
  • Is losing weight while conserving/improving muscle mass important to you?*
  • Have you ever been diagnosed as having anemia?*
  • Have you ever had issues with fatigue or low energy?*
  • Have you ever had issues with low vitamin levels or had to take a vitamin supplement?*
  • Would you like to have control over how forcefully and fast the medication is injected?*
  • During your weight loss journey would you like your doctor to be able to tailor your dosage to your personalized needs and goals?*
  • During your weight loss journey, would you like your doctor to be able to tailor your dosing frequency to your personalized needs and goals?*
  • Did you understand all the questions which were asked?*

  • Please type your FULL LEGAL NAME in lieu of your signature below after reviewing:

    Semaglutide, Wegovy, Ozempic, Saxenda are all in a group of drugs called "GLP-1's". These medications work on the body by :

    1. Increasing insulin production from the pancreas
    2. Decreasing glucagon release after a meal. Glucagon triggers your liver to store fat.
    3. Slows gastric emptying, which will make you feel ‘full’

    BENEFITS:

    • In a 68-week medical study of 1,961 adults living with obesity or excess weight with a related medical problem along with reduced-calorie diet and increased physical activity
    • Adults on average achieved ~12% weight loss (~38 pounds with an average)
    • People taking placebo in the study (not on medicine) lost an average of 6 lb (or ~2.5% body weight)
    • Average starting weight in both groups: ~232 lb
    • 83% of adults taking Wegovy® lost 5% or more weight, compared to 31% taking placebo
    • Weight loss has been shown to decrease the rates of diabetes type 2, cardiovascular disease, pain associated with osteoarthritis, and other co-morbidities.

    RISKS:

    • Common side effects include nausea, vomiting, diarrhea, constipation, and gastroesophageal reflux. Occasionally fatigue/headaches.
    • Medications in the GLP-1 family have caused thyroid tumors in lab mice. It is not yet known if medications in the GLP-1 family will cause thyroid tumors or medullary thyroid carcinoma (MTC) in people. No studies have confirmed a linkage between GLP-1 medications and thyroid tumors in humans, but if you have a history of family thyroid cancer you may want to discuss taking a GLP-1 with your primary care doctor.
  • Please provide a current, FULL body clothed photo of yourself.*
    • This is a requirement for weight loss therapy.
    • We take your privacy seriously and all photos are secured.
    • You can also upload a recent (last 1 month) photo from your camera roll or record a short video of yourself.

    You may skip this step for now if you like. You will be asked to upload a photo before you can receive your treatment.

  • Why is this required?
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    Our doctor needs to make sure that this medication is safe for you.

    This is mandatory to complete your medical intake.

    Please make sure to include your full body including your face.

    Please wear form-fitting clothing. Pictures with baggy clothing will be rejected.

    Don't worry, we take your privacy seriously, and these photos will remain within the medical chart.

     

  • Please provide a (Head-to-toe) Full Body clothed image of you so we can refer you to the doctor.

     

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  • ID Verification: We'll need a clear picture of a valid ID or driver's license so we can make sure the data you provided is accurate.*
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  • Here's your first message to your doctor. Please introduce yourself and feel free to:

    • Ask any questions you have
    • List any medical problem you have which were not discussed above
    • Include anything else you would like the doctor to know.
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  • Medications on your treatment plan might not be recommended for pregnant women.

  • Please acknowledge that you understand and agree to the following:

    I have filled out a medical intake form that will be used by a board certified physician that is licensed in my state to make a medical treatment plan for me. I understand all the questions that have been asked of me. The information that I have provided is accurate and complete. I am the patient who is consenting to be evaluated for treatment.

  • I acknowledge and agree to the above*

  • Medications we offer:

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  • Weight loss medications*
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  • Weight loss medications*
  • Should be Empty: