1. Eligibility & Safety

• I do not have a personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia type 2 (MEN2).
• I do not have chronic pancreatitis or a previous episode of pancreatitis (including GLP-1–related pancreatitis).
• I do not have a history of type 1 diabetes.
• I do not have severe gastrointestinal disease (e.g., Crohn’s disease or ulcerative colitis).
• I do not have a history of diabetic retinopathy.
• I have not had bariatric or other GI surgery within the last 6 months.
• I do not have a history of gallbladder disease.
• I do not have severe gastrointestinal disease (e.g., Crohn’s disease or ulcerative colitis).
• I do not have Severe liver disease/cirrhosis.
• I do not have Leber Hereditary Optic Neuropathy (LHON).
• I have not had an allergic reaction to GLP-1, liraglutide, or any other GLP-1 medication.

2. Information I Will Provide

• My weight (lbs) and height (feet & inches).
• Any medication allergies and any prior use of GLP-1 medicines (with dose and duration).
• My current medications/supplements and how long I’ve been taking them.
• How much weight I have lost since my last visit on my current dosage (if applicable).
• Any additional information I want my provider to know.

3. Required Health Confirmations

• I do not have elevated blood lipase levels, gastroparesis, a history of suicidal thoughts or attempts, or prior gastric bypass/gastric sleeve surgery.
• I have not had my gallbladder removed (cholecystectomy).
• I have not experienced adverse reactions such as abdominal distension, hoarse voice, trouble swallowing, a lump in the throat/neck, or vision disturbances from using GLP-1 medicines.

4. Monitoring & Side Effects

• I have reviewed the official medication guide: GLP-1 (FDA label).
• I understand potential side effects may include nausea, diarrhea, abdominal pain, headache, and other gastrointestinal symptoms. I will contact my provider or seek urgent care if severe or concerning symptoms occur.

5. Identification & Confidentiality

• Uploading a valid government-issued photo ID is a legal requirement to verify my identity before the consultation can be completed.
• This verification complies with state and federal telemedicine regulations.
• My personal information and ID will be handled securely, stored confidentially, and never shared except as required by law or to provide my medical care.

IMPORTANT: Please keep a clear photo of your Driver’s License or State ID or Passport (or photo of any government-issued ID) ready on this device to upload.

6. Consent, Risks & Liability

• I give my full consent for RightMD Inc. and its affiliated medical/pharmacy teams to evaluate, prescribe, and dispense GLP-1 for weight-management based on the information I provide.
• I accept the risks of therapy and understand outcomes are not guaranteed. To the extent permitted by law, RightMD Inc., its providers, pharmacies, and staff are not liable for adverse outcomes arising from my failure to disclose information, non-adherence, or misuse of the medication.

7. Payments & Refund Policy

• All purchases and services are final and non-refundable. Your payment will not be charged if you are not eligible for the services.

8. Policies

• I have read and agree to the Terms & Conditions, Privacy Policy, and Refund & Cancellation Policy.