Shapein Rx Form - Weight loss solutions

Step 1 of 7 · BMI Check

Let's see if you qualify

Enter your height and current weight to check eligibility for GLP-1 program.

Height

Current weight (lbs)

Please enter valid height and weight.

Step 2 of 7 · Motivation

What made you decide to check us out?

✓

Feel good in my body

I want to feel more confident and comfortable.

✓

More energy for life

I want energy to enjoy life and get through the day.

✓

Ready to take control

I'm tired of feeling stuck and want real change.

✓

Put my health first

I want a lasting, meaningful change.

Step 3 of 7 · Weight & Medication

Your weight goals & program

Weight (Optional)

Current (lbs)

Goal (lbs)

Which GLP-1 program are you interested in?

✓

Semaglutide + B12

GLP-1 blended with Vitamin B12 for enhanced results

Weekly injection

✓

Not sure — let the doctor decide

Our provider will recommend the best option for you

Provider recommended

Step 4 of 7 · Location

Where are you located?

State / Region

Step 5 of 7 · About you

A little about you

Full name

Phone

Gender

✓

Male

✓

Female

Step 6 of 7 · Consent

Almost there!

Where did you hear about us?

Please agree to both consent statements.

Step 7 of 7 · Review

Review your information

BMI—

Motivation—

Current weight—

Goal weight—

Medication—

Location—

Name—

Phone—

Email—

Gender—

Heard about us—

Unable to send. Please try again.

BMI Categories & Health Risks

BMI Range	Category	Health Risk
Below 18.5	Underweight	Possible nutrient deficiency
18.5 – 24.9	Healthy Weight	Low risk
25 – 29.9	Overweight	Increased risk
30 and above	Obese	High risk

Weight Loss

Compounded GLP-1 Medications

Branded GLP-1 Medications

Men’s Health

Erectile dysfunction

Testosterone

Women’s Health

Longevity+Vitality

NAD+ (Anti-Aging)

B12