*1.What is your first and last name?(Required.)

*2.What is your phone number?(Required.)

*3.How old are you?(Required.)

*4.Are you currently taking a GLP-1 medication? (Examples include: semaglutide (Ozempic®, Wegovy®, Rybelsus®), tirzepatide (Mounjaro®, Zepbound®), dulaglutide (Trulicity®), liraglutide (Saxenda®, Victoza®), exenatide (Byetta®, Bydureon®), lixisenatide (Adlyxin®).(Required.)

Yes

No

*5.What are you taking the medication for?(Required.)

Weight loss

Type 2 diabetes

Both

Other

N/A