Getting Started with A Better Weigh

1
What is your name?* This field is required.
First Name
Last Name
2
Why are you interested in A Better Weigh?* This field is required.Our programs are designed to deliver sustained, long-term weight loss and metabolic health, so if you're looking for a quick fix, our program may not be right for you.
I want to lose weight and keep it off
I want to improve my metabolic health after a diagnosis
I want to improve my quality of life
I want help creating healthier habits
3
In the past, how much have you spent on weight loss?* This field is required.Think about programs, medical support, gyms, meal plans, and other products or services you've tried. This info helps us understand the level of investment in your long-term metabolic health that is right for you.
$0-49/month
$50-99 per month
$100-149/month
$150-199 per month
$200+/month
I haven't tried to lost weight before
I have not spent anything
4
When is your birthday?* This field is required.
Date
Year
Month
Day
5
What is your biological sex?* This field is required.This is helps us order your lab tests.
Male
Female
Prefer not to answer
6
Do any of these apply to you?* This field is required.Our programs are safe and effective with many pre-existing conditions, with the exception of the following
Currently pregnant, or planning to become pregnant in the next year
Currently breastfeeding
Currently being treated for cancer
Active eating disorder
Active gallbladder disease
Active drug or alcohol abuse
Bariatric surgery (within the past 18 months)
History of pancreatitis
History of medullary thyroid cancer or MEN syndrome
None of above
7
Do you have Diabetes?* This field is required.This lets tailor or programs better to you
Yes
No
Unsure
8
Do you have difficulty managing your blood sugars?* This field is required.This lets tailor or programs better to you
Yes
No
Unsure
9
Do you have a higher risk of fall or dizzy spells than most people?* This field is required.
Yes
No
Unsure
10
What is your height and weight?* This field is required.We'll use this information to determine if our doctor-led approach is right for you.
Feet
Inches
Lbs
11
Email* This field is required.
example@example.com
12
What is your number?
Mobile phone number
Home number
13
What is your home address?This allows us ensure we assign a doctor that's registered to see you.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
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United States
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Burkina Faso
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Christmas Island
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Kenya
Kiribati
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Lithuania
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Macedonia
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Mali
Malta
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Martinique
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Mongolia
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Montserrat
Morocco
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Nagorno-Karabakh
Namibia
Nauru
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Netherlands
Netherlands Antilles
New Caledonia
New Zealand
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Niger
Nigeria
Niue
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Northern Mariana
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Paraguay
Peru
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Pitcairn Islands
Poland
Portugal
Puerto Rico
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Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
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Samoa
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eSwatini
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Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
14
What is your Provincial Health Number?We need this to order labs and facilitate your doctor visits.
15
What's your private insurance?Our team works closely with you and your private insurance to help maximize the coverage for GLP-1 medication our medical team may prescribe
Green Shield
Manulife
Sun Life
AISH
Great West Life
Canada Life
I do not have private insurance
I don't know
16
Does your private insurance have any drug approval forms for GLP-1 (e.g., Ozempic) or Contrave? Please upload hereIf you upload it here, we can fill the clinic portion of the form and send back so we can get ahead of any approval processes.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
17
What is the name and phone number of your preferred pharmacy?This allows us to send your prescription to a location convenient to you.
Name of Pharmacy
Phone number of pharmarcy
18
PatientId
19
CreatePatient
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