Appointment intake

Autosaved as you go - you won't lose information between steps.

Step 1 of 7
If unchecked, progress is saved only for this browser session (recommended on shared devices).
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Contact information

We'll send appointment updates and next steps to these details.

~1 minute
Please enter your first name.
Please enter your last name.
Please enter a valid email.
Please enter your phone number.
By continuing, you agree to receive messages about your appointment and account. Standard messaging rates may apply.

Eligibility basics

This helps us match you with the right appointment path.

~1 minute
Please select your state.
Please enter a valid age (18+).
Please enter your height.
Please enter your weight.
Please choose a goal.

Health history

Your provider uses this to evaluate safety and fit.

~2 minutes
Please enter your current medications (or write "none").

Weight loss goals

Helps your provider personalize your plan and expectations.

~2 minutes
Please select an option.
Please select an option.
Please tell us your target outcome.

Choose a treatment option

Select the option you're interested in. A provider will confirm what's clinically appropriate.

~1 minute
Important: This selection does not guarantee a prescription. Final decisions are made by your licensed provider after medical review.
Phentermine
Short-term appetite support (when clinically appropriate)
Highlights
  • Often used in shorter cycles
  • May support appetite control and adherence
  • Best for users who qualify after screening
Program policy (your rule)
Up to 6 doses in a cycle, then a 3-month rest before continuing.
Pricing (example)
Monthly: $XX - Includes consult + support
Tirzepatide
Ongoing program option (when clinically appropriate)
Highlights
  • Can be continued long-term under provider monitoring
  • 6 dosage levels (provider-guided titration)
  • Monthly or 3-month supply options
Dose set (example)
6 levels: 2.5 -> 5 -> 7.5 -> 10 -> 12.5 -> 15 (provider-directed)
Pricing (example)
Plan Monthly 3-Month
Starter dose range $XXX $XXX
Mid dose range $XXX $XXX
Advanced dose range $XXX $XXX
Replace pricing blocks above with your real pricing structure.
Confirm your selection
No selection yet.

Appointment preferences

Choose how you'd like to schedule your visit.

~1 minute
Please choose a scheduling option.
Connect now
This is where you can route the user to your immediate connection flow (video room / call queue / live chat).
Connect Now
Tip: your backend can assign a provider and return a secure meeting link for this user.
Your preferred appointment times
Select a preferred day.
Select a preferred time window.
Select a timezone.
Book your appointment
Select a date/time. This uses a lightweight calendar picker (Flatpickr). Your backend should: (1) validate availability, (2) reserve the slot, (3) email/SMS reminders, and (4) optionally attach a calendar invite (ICS).
Timezone is required.
Please select a date & time.
We will confirm availability on submit.
(Email/SMS reminders require backend integration using the captured email/phone.)
Please select a visit type.

Review & submit

Confirm your details before submitting your intake.

Final step
Your information
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Consent
Consent is required.
Consent is required.
Treatment (including prescriptions) is decided by the provider based on clinical appropriateness.
Your progress saves automatically as you type.

Complete payment to proceed

We'll begin processing your appointment immediately after payment.

Secure checkout
Order summary
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Payment
This is a placeholder. Redirect to your real payment/checkout route (PayTrace/Stripe/etc.).
Go to Checkout
After payment, show confirmation + next steps (provider review timeline, appointment link, reminders).
Note: you can also embed your hosted payment fields directly on this screen.