Pre-Qualification Form | VitalCore Health

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Your Contact Information

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Affiliate ID

Name*

First Last

Email*

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Phone

VitalCore Health and its affiliates may contact you via phone, and/or text (SMS) at the number provided using automated dialing technology for prescription notifications, including that my prescription may be due for a refill or expired; marketing; billing, or other financial content. You may always opt out of calls and SMS messages at anytime.

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Phone Contact Consent

Yes, I agree to the terms outlined below for use of my phone number

By checking this box/responding Yes, I authorize VitalCore Health and its affiliates to contact me via phone, and/or text (SMS) at the number I provided using automated dialing technology for prescription notifications, including that my prescription may be due for a refill or expired; marketing; billing, or other financial content. You are not required to respond “Yes!” in order to continue receiving goods or services. Message and data rates may apply. To opt-out at any time reply STOP to any text message or call us at store@vitalcore-health.com.

Name of referring physician/practitioner (if any):

Pre-qualifying Information

How old are you as of today?*

18 - 60 years

61 - 75 years

Over 75 years

Have you ever taken a GLP-1 medication or are you currently using one for weight loss?*

*Yes, I'm presently taking GLP-1 medications for the purposes of weight loss.

*Yes, I have taken GLP-1 medications for the purposes of weight loss in the past.

No, I am not and have not taken prescription drugs for weight loss.

*If your assigned medical provider determines that a compounded medication is medically necessary, it will be prepared according to their specific instructions. This may lead to adjustments in your dosage or other variations tailored to your individual health needs. By answering Yes to either statement, I'm agreeing that I understand this possibility for change.

How tall are you in inches?*

E.g., 5'5" would be 65 inches. 6'2" would be 74 inches.

What is your current weight in pounds?*

Tell Us More About Yourself

What are your weight and wellness goals?*

Check all that apply.

Feel more confident and better about myself

Be healthier overall

Look great for a special event

Improve appearance overall

Have more energy to keep up with life, family, work, etc.

Create a healthier relationship with food

Maintain existing weight loss

Other

How do you feel about embarking on a healthier lifestyle, including physical activity and better eating habits?*

What types of information interest you most?*

Healthy Eating Tips

Weight Loss Tips

Exercise Tips

Mental Health & Wellness Info

General Weight & Wellness Info

Weight Loss Success Stories

Tips for Staying on Track with Your Weight Loss Journey

Tips for Maintaining a Healthy Goal Weight

Other

What is your gender*

In what US state do you live?*

Affirmation & Consent

I agree to VCH's Privacy Policy and Terms & Conditions.*

By clicking the submit button below, I affirm that I have read, understand, and agree to VitalCore Health's Privacy Policy, Terms & Conditions, Disclaimer, Drug Safety Information, and Refund Policy.

Yes

I affirm that all information I provided in this form is true and accurate to the best of my knowledge and belief.*

I understand that providing false or misleading information may result in disqualification from treatment eligibility and could have legal or medical consequences.

Yes

Your Contact Information

Pre-qualifying Information

Tell Us More About Yourself

Affirmation & Consent

We're sorry, you do not qualify.

You are Amazing! Let's Begin.

You are Amazing! Let's Begin.