Reach your goal weight fast
without restrictive diets and exercise.

Please answer the following questions so we can qualify you for medical weight loss.

What is your height and weight? *

Feet

Inches

Weight (in lbs) *

What is your goal weight? *

Are you male or female? *

Male

Female

What is your date of birth? *

Month

Day

Year

Health Questions 1: Do any of these apply to you? *

End-stage kidney disease (on or about to be on dialysis)

End-stage liver disease (cirrhosis)

Current suicidal thoughts and/or prior suicidal attempt

Cancer (active diagnosis, active treatment, or in remission or cancer-free for less than 5 continuous years)

Severe gastrointestinal condition (gastroparesis, blockage, inflammatory bowel disease)

Current diagnosis of or treatment for alcohol, opioid, or substance use disorder/dependence

None of the above

⚠ For your safety, this answer may disqualify you from a prescription

Health Questions 2: Do any of these apply to you? *

Gallbladder disease

Hypertension (high blood pressure)

Seizures

Glaucoma

Sleep apnea

Type 2 diabetes (not on insulin)

Type 2 diabetes (on insulin)

Type 1 diabetes

Diabetic retinopathy (diabetic eye disease), damage to the optic nerve from trauma or reduced blood flow, or blindness

Use of the blood thinner warfarin (Coumadin/Jantoven)

History of or current pancreatitis

Personal or family history of thyroid cyst/nodule, thyroid cancer, medullary thyroid carcinoma, or multiple endocrine neoplasia syndrome type 2

Gout

High cholesterol or triglycerides

Depression

Head injury

Tumor/infection in brain/spinal cord

Low sodium

Liver disease, including fatty liver

Kidney disease

Elevated resting heart rate (tachycardia)

Coronary artery disease or heart attack/stroke in last 2 years

Allergic to any medication

Congestive heart failure

QT prolongation or other heart rhythm disorder

Hospitalization within the last 1 year

Human immunodeficiency virus (HIV)

Acid reflux

Asthma/reactive airway disease

Urinary stress incontinence

Polycystic ovarian syndrome (PCOS)

Clinically proven low testosterone

Osteoarthritis

Constipation

None of the above

Within the last 3 months, have you taken opiate pain medications and/or opiate-based street drugs? *

Yes

Have you had prior weight loss surgeries? *

Yes

Do you currently take any prescription medications? *

Yes

What is your blood pressure range? *

<120/80 (Normal)

120 to 129/<80 (Elevated)

130 to 139/80-89 (High Stage 1)

≥140/90 (High Stage 2)

What is your average resting heart rate? *

<60 beats per minute (Slow)

60 to 100 beats per minute (Normal)

101 to 110 beats per minute (Slightly Fast)

>110 beats per minute (Fast)

"When nothing else worked...
ProMultis did!"

Are you ready for your next chapter?

Your Details

Name *

Email *

Phone number *

State *

✓

You're eligible for the ProMultis Weight Loss Program!

Based on your profile:

—

Current

—

Goal

—

Est. Loss

Licensed physician consultation
Compounded GLP-1 medication
Cold-chain delivery to your door
Ongoing medical monitoring
24/7 care team support

First month $179, then $299/month. Cancel anytime.

⚠

We're unable to enroll you at this time

Based on your health information, our program may not be the right fit right now. We recommend consulting with your primary care physician about weight management options.

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