Adept Rx

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Thank you for choosing Adept Rx. 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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First, we need to make sure we are licensed in your state*

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.

What is your full name?*

First NameLast Name

What is your email address?*
example@example.com
By Checking Here… You agree to receive doctor correspondence, transactional and/or marketing messaging from Adept Rx, to the email address that you provided above.

Please enter the best phone number to reach you on just in case the doctor has any questions regarding your medical information.*
Please enter a valid phone number.
Can we also send you text messages about your prescription including tracking information and refill information?*

YesNo
By checking this box, I also consent by electronic signature to receive phone calls and/or SMS text messages at the phone number(s) below, including my wireless number if provided. I understand these calls may be generated using an automated technology, pre-recorded voices and that data rates may apply. I understand that my consent is not required to buy goods/services and I may opt out at any time to avoid receiving calls or SMS text messages.

What is your date of birth?*

MonthDayYear

today*

MonthDayYear
Date
age*
Phone Number
Please enter a valid phone number.
Sorry, you must be over 18 to use this service

What is your gender?*

Your height, Feet/inches:*
feet
inches
Height (Inches)*
Your weight, LBS:*
lbs
BMI
Please confirm your height and weight are correct, as these are crucial to your doctor's prescription decision.

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).
We require that you provide a recent blood pressure measurement within the last six months.*
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?*

Yes - Please list your medical conditionsNo - I affirm I have no known medical conditions
Medical Conditions*

Are you taking any medications?*

Yes - Please list the names and dosagesNo - I affirm I'm not taking any medications
Note: Many medications have interactions. Your doctor needs to know every medication that you take to help avoiding any harmful interactions.
Current Medications*

Do you have any allergies or intolerances?

Yes - Please list your allergies and any known reactionNo - I affirm I have no known drug allergies
Allergies*

Are you here to be evaluated for weight loss?*

YesNo
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?*

YesNo, this would be my first time
Examples may include caloric restriction through diet, exercise, or behavior modification.
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Are you willing to reduce your caloric intake alongside medication?*

YesNo
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Please provide details about why caloric restriction is not appropriate for you*
Caloric Restriction Notes

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?*

YesNo
Please provide details about why physical activity is not appropriate for you.*
Physical Activity Notes
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We're sorry that you're not willing to help participate in weight loss through physical activity.

What is your goal weight?*
Please answer in pounds

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

Less than a year ago1 to 2 yearsMore than 2 years ago
lastMedicalEval-IMP
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?*

YesNo, not at this time
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.
Select multiple files or drag and drop them hereTake a live picture
Take a live picture*
Select multiple files or drag and drop them here*

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Do you have any of the following?*

High CholesterolFatty Liver DiseaseHigh Blood PressureObstructive Sleep ApneaPrediabetes/ Type 2 Diabetes / HbA1C above 5.7None of the above
haveConditionsListed-IMP
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.
none_1*
Please uncheck "None of the above" if you have other selections.

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

MEN2 (multiple endocrine neoplasia syndrome type 2)Medullary thyroid cancerNONE of the above
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Are you sure your family member has medullary thyroid cancer?*
Please tell the doctor more if you are not sure. Papillary thyroid cancer, hashimotos thyroiditis and simple hypothyroid disorder is not a problem. Use the back button if you need to change your answer.
familyMedullaryDetails-IMP
none_3*
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?*

Leber optic nerve atrophyCyanocobalamin hypersensitivity (allergy)Benzyl Alcohol AllergyNONE of the above
q_contra_conditions-IMP
none_5*
Please uncheck "NONE of the above" if you have other selections.

Do you have any of the following?*

History of kidney failureHistory of chronic renal failureSeen a kidney specialist in the past 12 monthsHistory of solitary kidney, or kidney transplantNONE of the above
q_conditions_kidney-IMP
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 tell the doctor more:Please 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*
We require that you provide a recent blood pressure measurement within the last 6 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).
kidneyLabDetails-IMP
none_4*
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*

YES, I CONSENT to being treated with GLP-1 agonists. I have reviewed the risks and benefits above.NO, I DO NOT consent to being treated with a GLP-1
glp1_consent-IMP

Would you like a prescription of nausea medication to be sent to your local pharmacy?*

Yes. I understand this is different than the medication to help with appetite suppression/weight loss which will be sent directly to me. I will need to go pick this up and pay for it with my own insurance or out of pocket.No thank you
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.
I have reviewed the Florida Bill of Rights for Weight LossI was unable to view the Florida Bill of Rights for Weight Loss
Please review the Florida Bill of Rights for Weight Loss:
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If your treatment made you significantly nauseated or caused other GI side effects would that impact your compliance with treatment and willingness to continue?*

YesNo

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?*

YesNo

In any prior attempts to lose weight, do you feel you experienced loss of muscle as well?*

YesNo

Is losing weight while conserving/improving muscle mass important to you?*

YesNo

Have you ever been diagnosed as having anemia?*

YesNo

Have you ever had issues with fatigue or low energy?*

YesNo

Have you ever had issues with low vitamin levels or had to take a vitamin supplement?*

YesNo

Would you like to have control over how forcefully and fast the medication is injected?*

YesNo

During your weight loss journey would you like your doctor to be able to tailor your dosage to your personalized needs and goals?*

YesNo

During your weight loss journey, would you like your doctor to be able to tailor your dosing frequency to your personalized needs and goals?*

YesNo

Did you understand all the questions which were asked?*

YesNo
Which question did you not understand?*
Please give as much information as possible
whichQuestion-IMP

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.
GLP-1 Risks Acknowledgement:

Please provide a current, FULL body clothed photo of yourself.*

Take a live picture (Preferred)Select multiple files or drag and drop them hereI am not able to do this now but will provide it later
- 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?
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.
Customer understands FullBody photo will be needed
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Please provide a (Head-to-toe) Full Body clothed image of you so we can refer you to the doctor.
Take Photo*
File Upload*

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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.*

Take a photoUpload ID
id_camera*
id_upload*

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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.
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.
I acknowledge and agree to the above*

I acknowledge and agree to the aboveI do not acknowledge and agree to the above
acknowledge-IMP*

Medications we offer:
Weight loss medications*

Compounded Semaglutide (up to 0.25mg/weekly) for
$212Compounded Semaglutide (up to 0.5mg/weekly) for
$212Compounded Semaglutide (up to 1mg/weekly) for
$212Compounded Semaglutide (up to 1.7mg/weekly) for
$212Compounded Semaglutide (up to 2.4mg/weekly) for
$212
Weight loss medications*

Compounded Semaglutide (Starting Dose) for
$212
sku*
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Medications we offer: