Check Eligibility — Solstice Clinical

Step 1 of 9

What's your name?

First Name

Last Name

Please enter your first and last name.

Step 2 of 9

How can we reach you?

Email Address

Please enter a valid email address.

Phone Number

Please enter a phone number.

Step 3 of 9

Height and weight

Used to confirm eligibility for GLP-1 therapy.

Height

Weight (lbs)

Please enter your height and weight.

Step 4 of 9

Have you previously used a GLP-1 medication?

Examples: Ozempic, Wegovy, Zepbound, Mounjaro, Saxenda, Victoza, Foundayo, or any compounded GLP-1 with or without additive

Please select an option.

Step 5 of 9

Do you have any medication allergies?

List medication allergies

Please select an option.

Step 6 of 9

Are you currently taking any prescription medications?

List current medications

Please select an option.

Step 7 of 9

Do you have any ongoing medical conditions?

List medical conditions

Please select an option.

Step 8 of 9

A few safety questions

Please answer honestly. Select all that apply to you.

I have ever had pancreatitis.

I or a family member have a history of medullary thyroid cancer (MTC) or MEN2.

I am currently pregnant, breastfeeding, or planning pregnancy.

I have severe gastroparesis or delayed stomach emptying.

Step 9 of 9

Before we submit

All four statements must be confirmed to continue.

I understand this consultation is for evaluation of GLP-1 prescription eligibility. I confirm that the information I have provided is accurate and complete to the best of my knowledge.

I understand that Solstice Clinical does not provide emergency care or ongoing management of medication complications. In an emergency, I will call 911 or go to the nearest emergency room.

I understand that completing this intake does not guarantee a prescription. The prescribing clinician makes the final determination based on a review of my information.

I understand that my subscription renews automatically each month. I may cancel at any time before the next billing date by contacting Solstice Clinical.

All four statements must be confirmed to continue.

What's your name?

How can we reach you?

Height and weight

Have you previously used a GLP-1 medication?

Do you have any medication allergies?

Are you currently taking any prescription medications?

Do you have any ongoing medical conditions?

A few safety questions

Before we submit

You appear eligible for a Solstice Clinical consultation.

Thank you for completing the intake.

Thank you for completing the Solstice Clinical intake.