Step 1 of 9

Choose your treatment

Select the medication that's right for your goals. Your provider will confirm eligibility after reviewing your health profile.

Health screening

Your safety is our priority. Please indicate if any of the following apply to you.

Select all that apply. Some conditions may require additional provider review. Checking a box does not automatically disqualify you.

End-stage liver disease (cirrhosis)

Current or prior eating disorder (anorexia or bulimia)

Current suicidal thoughts or prior suicide attempt

Cancer (active diagnosis or currently in treatment)

History of organ transplant or taking anti-rejection medications

Severe GI condition (gastroparesis, inflammatory bowel disease)

Untreated opioid, alcohol, or substance dependence

Personal or family history of medullary thyroid cancer (MTC) or MEN2

Type 2 diabetes on insulin or A1c greater than 10%

Type 1 diabetes

Diabetic retinopathy, optic nerve damage, or blindness

Currently taking Warfarin (Coumadin/Jantoven)

History of or current pancreatitis

Currently pregnant, breastfeeding, or planning pregnancy within 2 months

Based on your responses, you may not be eligible for GLP-1 treatment at this time. We recommend speaking with your primary care physician. If you believe this is an error, please contact us at support@clyr.health.

Step 3 of 9

Your details

We'll use this to set up your account and connect you with a licensed provider in your state.

First name *

Last name *

Email address *

Please enter a valid email address

Phone number *

Date of birth *

Biological sex *

Height & weight *

--

BMI: --

Enter height & weight

Step 4 of 9

Medical history

Help your provider understand your background so they can create the best treatment plan for you.

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

✓ Yes

— No, first time

Are you willing to reduce your caloric intake alongside medication?

👍 Yes

👎 No

Are you willing to increase your physical activity alongside medication?

🏃 Yes

✗ No

Are you CURRENTLY taking any prescription medications for weight loss?

None at this time

Wegovy / Zepbound / Mounjaro / Ozempic / Trulicity / Saxenda

Compounded Semaglutide

Compounded Tirzepatide

Other medication not listed

What is your goal weight? (lbs)

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

Less than a year ago

1 to 2 years ago

More than 2 years ago

Have you had any lab tests completed within the last 6 months?

🔬 Yes

— No, not at this time

Are you currently taking any medications?

💊 Yes

— No medications

Do you have any drug allergies or intolerances?

⚠️ Yes

— No allergies

Step 5 of 9

Treatment preferences

These help your provider personalize your treatment plan and manage potential side effects.

Would you like a prescription for nausea medication sent to your local pharmacy?

This is separate from your GLP-1 treatment and may require a co-pay or out-of-pocket cost.

💊 Yes, please

— No, thank you

How sensitive are you to nausea or motion sickness?

5

1 — Not sensitive10 — Extremely sensitive

Tell us about your preferences

Toggle the options that apply to you. These help your doctor customize your treatment.

If I had significant nausea or GI side effects, it would impact my willingness to continue treatment

Minimizing nausea and GI side effects during treatment is important to me

In prior weight loss attempts, I experienced loss of muscle mass

Losing weight while conserving or improving muscle mass is important to me

I have been diagnosed with anemia

I have experienced fatigue or low energy

I have had issues with low vitamin levels or taken vitamin supplements

I want control over how forcefully and fast the medication is injected

I want my doctor to tailor my dosage to my personalized needs and goals

I want my doctor to tailor my dosing frequency to my personalized needs and goals

Step 6 of 9

Almost there

Review important information about GLP-1 treatment, sign your name, and introduce yourself to your provider.

Please read the following about GLP-1 medications

✓ YES, I CONSENT to GLP-1 treatment

✗ No, I do not consent

Please type your FULL LEGAL NAME as your electronic signature

By typing your name, you certify that the information provided is accurate and complete.

Send a message to your doctor

Introduce yourself and share anything you'd like your provider to know about your health goals, concerns, or medical history.

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Step 7 of 9

Shipping address

Your medication will be shipped directly to you from our licensed compounding pharmacy.

Street address *

Enter your full street address

Apartment, suite, etc.

City *

State *

ZIP code *

Step 8 of 9

Review & checkout

Please confirm your information below. You'll complete payment securely via Stripe.

Treatment & Plan

—

Selected Plan —

Personal Information

Name —

Email —

Phone —

Date of Birth —

Biological Sex —

Height / Weight / BMI —

Shipping Address

—

Medical History

Prior weight management —

Current weight loss Rx —

Goal weight —

Last medical evaluation —

Treatment Consent

GLP-1 Consent —

Legal signature —

By clicking "Continue to Checkout," your information will be sent to a licensed provider for review. If your provider determines you are not eligible for treatment, you will receive a full refund. Compounded medications have not been evaluated or approved by the FDA for safety, efficacy, or quality.

Step 9 of 9