What results or benefits are most important to you?

General Wellness Anti-Aging Antioxidant Benefits Boost Energy Brighten Skin Detoxification Immune Support

Gender & hormones impact the way your body ages.

Male

Female

Do you have a known history of glucose-6-phosphate dehydrogenase (G6PD) deficiency, chronic kidney disease (CKD) or liver cirrhosis?

No Yes

Are you currently undergoing treatment for cancer, including chemotherapy or radiation therapy?

No Yes

Great, a lot of this should feel familiar then.

With Tummala Health, you'll do your labs at home with step-by-step guidance.

Select the state you live in:

This state is where your medication will be shipped to, if prescribed.

To verify your eligibility, tell us your date of birth:

Date of birth

Create Your Account

Create your account to keep going with your journey, we will ask you a few more questions for our third party partner gathers all the information necessary.

What is your primary goal for weight loss?

Overall health improvement Specific weight loss target Increased energy Improved body composition Other

How much weight would you like to lose?

10-20 lbs 20-40 lbs 40-50 lbs 100+ lbs Not sure

Do you exercise?

Yes No

Have you had any previous weight loss attempts or programs?

Yes No

Do you have Diabetes?

I do not have Diabetes. I have Diabetes.

Which of the following applies to you?

I have Diabetes, but I do not take any medication. I take Metformin only. I take Insulin (Humalog, NovoLog, Lantus, Levemir, Toujeo). I take a DPP4 inhibitor (Januvia, Tradjenta). I take a Sulfonurea (Glipizide, Glyburide, Glimepiride). I take a Glinide (Repaglinide, Nateglinide).

Do you have a personal or family history (grandparents, parents, siblings, or children) of thyroid cancer?

Yes No

Please upload your pathology report. (If you cannot provide a pathology report, you do not qualify for treatment.)

Choose document or picture No file selected JPG, PNG, WebP, PDF, DOC, or DOCX — maximum 5 MB.

Do any of the following apply to you?

None of the below applies to me. Arrhythmia? Bulimia? Planning to become pregnant Breast cancer and on Aromatase inhibitors (Anastrozole, Letrozole, Exemestane), SERM’s (Tamoxifen, Toremifene) or SERD’s (Fulvestrant).

Are you on the following?

I am not on any of the medications listed Sotalol or Flecainide

GLP-1 medication can interact with Warfarin and affect your INR. This means to take a GLP-1 you must monitor your INR more carefully, particularly each time you have a dose increase. Please inform your PCP, cardiologist and anti-coagulation clinic that you are planning to take a GLP-1 medication and make sure you follow their advice and care plan as prescribed.

I have read the above and acknowledge the risk vs. benefit of taking a GLP-1 while taking Warfarin. I agree to follow the above recommendations, and the advice of my physicians. I agree to monitor my INR carefully and work with my physicians and anti-coagulation clinic as necessary to keep my INR in prescribed range.

When was the last time you injected a GLP-1 medication?

30 days or less It has been over 30 days but less than 60 days. Over 60 days (If you have not been on treatment within the last 60 days, you will need to restart treatment at the initial starting dose) I have never taken GLPs

What was your weight when you started the GLP-1 medication? (In pounds)

Maximum 5,000 characters.

Which weight loss medication are you currently taking?

Semaglutide (Wegovy, Ozempic) Tirzepatide (Mounjaro, Zepbound) Liraglutide (Saxenda) Other Weight Loss Medication

What was the last dosage you took? (Doses can be customized for patient needs - please select the dose most similar to your last weekly dosage. If you are unsure, please select Other.)

0.25mg weekly 0.5mg weekly 0.75mg weekly 1mg weekly 1.5mg weekly 1.7mg weekly 2mg weekly 2.5mg weekly Other

What was the last dosage you took?

Maximum 5,000 characters.

Please upload an image of your most recent vial or prescription (Must include - name, date of prescription, medication, and dosage.)

Upload now If you cannot provide proof of your current dosage, then you will need to start treatment at the initial dose

Please upload your script or a picture of your current vial.

Choose document or picture No file selected JPG, PNG, WebP, PDF, DOC, or DOCX — maximum 5 MB.

What was the last dosage you took? (Doses can be customized for patient needs - please select the dose most similar to your last weekly dosage. If you are unsure, please select Other.)

2.5mg weekly 5mg weekly 7.5mg weekly 10mg weekly 12.5mg weekly 15mg weekly Other

How long have you been taking the medication consecutively?

One month Two months Three months Four months Five months Six months More than six months

How long have you been on your current dose?

Less than one month One month Two months Three months Four months Five months SIx months More than six months

Please select the option that best reflects how you’d like to move forward with dosing. Your provider will use this information as part of their clinical assessment and make the final decision.

Increase dose monthly according to regular schedule Maintain your current dose monthly Increase dose this month and then maintain that dose monthly Decrease dose this month and then maintain that dose monthly

Have you been taking the medication as prescribed?

Yes No

Please explain how you have deviated from the dosing instructions.

Choose document or picture No file selected JPG, PNG, WebP, PDF, DOC, or DOCX — maximum 5 MB.

What was your weight when you started the GLP-1 medication? (In pounds)

Maximum 5,000 characters.

Please select the option that best reflects how you’d like to move forward with dosing. Your provider will use this information as part of their clinical assessment and make the final decision.

Increase the dose monthly according to a regular schedule Increase the dose after the initial month and then maintain that dose monthly Maintain the starting dose monthly It has been over 30 days but less than 60 days Over 60 days (If you have not been on treatment within the last 60 days, you will need to restart treatment at the initial starting dose) I have never taken GLPs

Please select the option that best reflects how you’d like to move forward with dosing. Your provider will use this information as part of their clinical assessment and make the final decision.

Increase the dose monthly according to a regular schedule Maintain the starting dose for a quarterly supply and increase my dose for the next quarterly supply

Your medical provider might contact you for a phone consultation. Otherwise, they will review your intake forms and approve your prescription if all requirements are satisfied.

I understand that my medical provider may need to contact me by phone before prescribing, and I will be reachable. I do not need to speak with my medical provider. I understand that a phone consult may not be required unless required by the state in which I live. I am still requesting to speak with my medical provider

I understand that by requesting to speak to my medical provider, an adjusted charge may occur.

I do not agree to the adjusted charge and do not wish to speak with my medical provider I agree to an adjusted charge and would like to speak with my medical provider

Please tell us what you'd like to discuss with your medical provider. (e.g., medication contraindications, medical condition contraindications, etc.)

Maximum 5,000 characters.

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What results or benefits are most important to you?

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