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What is your weight loss goal?(Required)

I haven't decided

Lose 1-20 lbs

Lose 21-50 lbs

Lose over 50 lbs

Maintain my weight and get fit

What is your current height & weight?

Your BMI

0.0

Feet(Required)

Please enter a number from 1 to 8.

Inches(Required)

Please enter a number from 0 to 11.

Current Weight(Required)

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BMI

What was your sex assigned at birth?(Required)

Please select your sex.

Female

Male

Are you pregnant, planning on becoming pregnant, or nursing?(Required)

Yes

What is your date of birth?(Required)

MM slash DD slash YYYY

Where are you located?(Required)

We only work with licensed providers in your state who specialize in weight loss.

Here are the treatment options available in your state.

All our medications are shipped from a licensed 503A compounding pharmacy in compliance with FDA Section 503A.

Our Sublinguals(Required)

Semaglutide

Tirzepatide

Tirzepatide + Tadalafil (for erectile dysfunction)

We only work with a licensed compounding pharmacy. All our medications go through a rigorous testing process before arriving at your door.

Three smiling pharmacists stand together wearing lab coats. The text reads

What is your goal weight?(Required)

What is the highest weight you have ever reached?(Required)

Are you here to be evaluated for weight loss?(Required)

All responses will be evaluated by a board-certified clinician. Medication may be prescribed for appropriate candidates.

Yes

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

Examples may include caloric restriction through diet, exercise, or behavior modification.

Yes

Are you willing to increase your physical activity alongside medication?(Required)

Yes

Are you ready to lose weight safely & quickly?

Woman exercising with foam roller alongside graphic showing 14.9% average body weight reduction, equal to 55 pounds lost after 6 months from a starting weight of 365 lbs.

Are you willing to reduce your caloric intake alongside medication?(Required)

Yes

Now, let's go through your health history.

A medical provider takes notes on a chart while giving a consultation to a patient.

Do you have any of the following?(Required)

Pre-diabetes/ Type 2 Diabetes / Hba1c above 5.7

Fatty Liver Disease

High Cholesterol

High Blood Pressure

None of the above

Please read the following about all GLP-1s.(Required)

Common Names (Alphabetical Order):

Liraglutide (Brand: Saxenda)

Semaglutide (Brands: Ozempic, Rybelsus, Wegovy)

Tirzepatide (Brand: Mounjaro)

How They Work:

These medications function by:

Increasing insulin production from the pancreas.

Appetite suppression by reduction of cravings and ‘food noise.’

Slowing gastric emptying, which helps you feel fuller for longer.

Efficacy:

GLP-1s have been shown to aid in weight reduction, particularly when combined with lifestyle modifications such as regular exercise and a reduced caloric intake.

YES, I CONSENT to being treated with GLP-1 agonists. I have reviewed the risks and benefits above.

At Get Relief, our patients tell us these are the reasons they want our GLP medication. Tell us why you need our under the tongue (sublingual) option.(Required)

Significant difficulty with self injections (fear of needles or difficulty holding syringe)

Can’t swallow tablets or capsules

Altered digestive system (e.g., post-bariatric surgery) affecting oral medication absorption.

History of pain or reactions at injection sites

Easier to remember daily dosing

None of the above

No waiting at the doctor's office.

GetReliefRX graphic with provider portrait and message that applications are approved quickly by a licensed provider without waiting for a doctor's appointment.

Have you undergone gallbladder removal, cholecystectomy, or gallstones in the past?(Required)

Yes

How long ago did you have your gallbladder removed, a cholecystectomy, or gallstones?(Required)

Less than six months

Six months or longer

Do you have a history of pancreatitis, type‑1 diabetes, GI diseases such as Crohn's disease, or ulcers, diabetic retinopathy, medullary thyroid cancer, MEN‑2 (multiple endocrine neoplasia syndrome type 2)?(Required)

Yes

Do you have a history of ascites, cirrhosis, or liver disease?(Required)

Yes

Please select the severity of your cirrhosis or liver disease.(Required)

Mild

Moderate

Severe

Please provide details of your cirrhosis and/or liver disease(e.g., diagnosis, type, or current treatment).(Required)

Do you have chronic kidney disease or a history of kidney diseases?(Required)

Yes

Do you know your current kidney function number (eGFR)?(Required)

My eGFR is 60 or higher (normal or near-normal kidney function)

My eGFR is between 45-59 (mildly reduced kidney function)

My eGFR is between 30-44 (moderately reduced kidney function)

My eGFR is between 15-29 (severely reduced kidney function)

My eGFR is less than 15 (very severe reduced kidney function)

I don't know my eGFR number

Are you currently on dialysis?(Required)

Yes

Have you had a kidney transplant?(Required)

Yes

Are you currently taking any prescription medications for weight loss?(Required)

Yes

Which weight loss medication are you currently taking?(Required)

Semaglutide (Ozempic®)

Semaglutide (Wegovy®)

Tirzepatide (Mounjaro®)

Liraglutide (Saxenda®)

Phentermine

Phentermine/Topiramate (Qsymia®)

Orlistat (Alli®, Xenical®)

Bupropion/Naltrexone (Contrave®)

Topiramate

Metformin

Naltrexone

Bupropion

Other

Please tell use the current dosage, duration of the medication, and the last time it was used.(Required)

GLP-1 Medication Consent(Required)

If you are prescribed a GLP-1 medication through GetReliefRX, you must agree to discontinue the use of any current GLP-1 medication (including, but not limited to, brand-name or compounded formulations) to ensure safe and coordinated care.

By checking "I agree" you acknowledge and agree to the following:

You will stop taking your current GLP-1 medication upon initiation of the medication prescribed through GetReliefRX.

You will notify the licensed healthcare provider who originally prescribed your current GLP-1 medication prior to discontinuation.

You understand that concurrent use of multiple GLP-1 medications may increase the risk of adverse effects and is not recommended.

I agree to discontinue my current GLP-1 medication and will notify my prescribing healthcare provider prior to doing so.

Are you taking any other medications/supplements?(Required)

Make sure to tell us about any birth control, diabetes, anticoagulation, or any other prescription medication here.

Yes

Please list all other medications/supplements you're currently using.(Required)

Please include the dosage, frequency, and the last time you used each medication.

Do you have a family history of MEN2 or medullary thyroid cancer?(Required)

Yes

When did you first notice symptoms of erectile dysfunction?(Required)

Less than 3 months ago

3-6 months ago

6-12 months ago

More than 12 months ago

How often do you experience difficulty achieving or maintaining an erection?(Required)

Occasionally (less than 25% of the time)

Frequently (25–50% of the time)

Most of the time (more than 50% of the time)

Always

Do you have morning or nocturnal erections?(Required)

Yes

Are you currently taking nitrate medications (e.g., nitroglycerin, isosorbide) for heart conditions?(Required)

Yes

Have you had any of the following cardiovascular events or conditions?(Required)

Heart attack within the past 6 weeks

Stroke within the past 6 months

Severe heart failure (e.g., difficulty breathing at rest or with minimal activity)

Shortness of breath

Chest pain

Any diagnosis followed by a cardiologist

None of the above

Do you have any of the following conditions that may contribute to erectile dysfunction?(Required)

Neurological conditions (e.g., multiple sclerosis, Parkinson’s disease, spinal cord injury)

Hormonal disorders (e.g., low testosterone, thyroid dysfunction)

Pelvic or prostate surgery/trauma, or cancer

Enlarged prostate

Anatomical penile deformities (e.g., Peyronie’s disease)

None of the above

Which of the following lifestyle factors apply to you?(Required)

Use of recreational drugs (e.g., cocaine, methamphetamines)

Excessive alcohol consumption (more than 14 drinks per week)

Tobacco use (e.g., smoking, chewing tobacco)

None of the above

Have you ever taken medications for erectile dysfunction (e.g., sildenafil, tadalafil)?(Required)

Yes

Please describe your experience (e.g., effectiveness, side effects).(Required)

Do you have a history of any of the following eye conditions?(Required)

Retinitis Pigmentosa

Anterior Ischemic Optic Neuropathy (AION)

History of sudden vision loss in one or both eyes

Central Serous Chorioretinopathy

Glaucoma

Other eye conditions

None of the above

Please explain your eye condition.(Required)

Do you have a history of any of the following medical conditions?(Required)

Hypertension (high blood pressure)

High cholesterol

Liver disease (e.g., cirrhosis, hepatitis)

None of the above

What is your current or average blood pressure range?(Required)

<120/80 (Normal)

120-129/<80 (Elevated)

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

>140/90+ (High Stage 2)

I don't know

Do you have any allergies?(Required)

None

Fruit

Medications

Other

Please list your allergies.(Required)

Do you have any medical conditions we should know about?(Required)

Yes

Please list all medical conditions below.(Required)

Shipping Information

We have options to deliver medication right to your door.

Address(Required)

Address Line 1 Address Line 2 City State ZIP Code

Phone(Required)

Name(Required)

First Name Last Name

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By checking this box, I agree to receive marketing and promotional text messages from GetReliefRX, including special offers, product updates, and promotional campaigns. Messages may be sent using automated technology.
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What is your email?

We will use this email to create your personal patient portal login where you can talk to your provider and manage your subscription.

Email Address(Required)

Consent & Acknowledgment(Required)

By clicking Continue, I confirm that I have answered this survey truthfully to help tailor my treatment. I agree to the following:

Side Effects Acknowledgment precaution

Telehealth consent

GLP-1/GIP Medication Information

Medication adjustment acknowledgement

I have read and agree to the consents and acknowledgments above.

We only work with a licensed compounding pharmacy. All our medications go through a rigorous testing process before arriving at your door.

Now, let's go through your health history.

No waiting at the doctor's office.

Shipping Information

Resources

Partners

Contact

Trust & Social

We only work with a licensed compounding pharmacy. All our medications go through a rigorous testing process before arriving at your door.

Now, let's go through your health history.

No waiting at the doctor's office.

Shipping Information

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