Strata GLP-1 Program - Application

Personal Information

Tell us who you are. A licensed provider uses this to set up your clinical review.

First Name *

Last Name *

Email *

Phone *

Date of Birth & Sex

Your date of birth confirms you meet the program’s age requirements. Sex at birth determines which screening questions you see.

Date of Birth *

Sex Assigned at Birth *

Pregnancy Screening

Are you currently pregnant? *

Yes No

Are you currently breastfeeding? *

Yes No

Are you planning to become pregnant? *

Yes No

What is your current height and weight?

Used to calculate BMI for clinical eligibility.

Feet (ft) *

Inches (in)

Weight (lbs) *

Shipping Information

Your medication will ship to this address, so please make sure it's complete and accurate.

Street address *

Apt / Unit / Suite (optional)

City *

State *

ZIP code *

Your Goals & Medication

What is your primary goal for this program? *

Weight loss Metabolic & blood-sugar health Longevity / healthspan Other

Which medication are you interested in? *

How Semaglutide and Tirzepatide compare
Semaglutide	Tirzepatide
Mimics the GLP-1 hormone.	Mimics both GLP-1 and GIP hormones.
Helps reduce appetite, slows stomach emptying, and improves blood sugar control.	Works similarly but also activates GIP receptors, which may provide greater effects on blood sugar and weight loss for some patients.
Approved for type 2 diabetes and chronic weight management (under specific brand indications).	Approved for type 2 diabetes and chronic weight management (under specific brand indications).
Average weight loss is significant, but individual results vary.	Clinical studies have shown greater average weight loss than semaglutide for many patients, though results vary by individual.
Common side effects include nausea, vomiting, diarrhea, constipation, and decreased appetite.	Similar side effects, with gastrointestinal symptoms being the most common.
Usually given as a once-weekly injection.	Also given as a once-weekly injection.

Compound Semaglutide (Injection) Loading price… Compound Tirzepatide (Injection) Loading price…

*Billed quarterly. A 90-day supply is shipped and billed for all three months upon scripting of your medication.

Medication History

Are you currently taking a GLP-1 medication? *

Yes No

Have you ever taken a GLP-1 medication in the past (even if not currently)? *

Yes No

Current diabetes medications (if any)

Current insulin dose (if applicable)

Medical History: GI & Endocrine

Do you have any of the following conditions? *

Medical History: Kidney

Do you have any of the following conditions? *

GLP-1 Safety Screening

These questions help identify any contraindications for GLP-1 receptor agonist therapy.

Have you ever had an allergic reaction to any GLP-1 medication (e.g., semaglutide, tirzepatide, liraglutide)? *

Yes No

Do you experience known episodes of hypoglycemia (low blood sugar)? *

Yes No

Lifestyle & Readiness

Help us understand your current habits and readiness for the program.

Do you experience any digestive symptoms (bloating, gas, constipation, loose stools, etc.) on a regular basis?

How often do you engage in physical activity or exercise? *

Rarely 1-2 times per week 3-5 times per week Daily

On a scale of 1-10, how ready do you feel to make changes to your health habits right now? *

Not ready Very ready

5

Do you feel supported by family, friends, or your community in your health goals? *

Yes Somewhat No

What motivates you most to pursue this program?

Medical Background

This information goes to your provider. Please be as complete as you can.

Please list any prior or ongoing medical problems or conditions not already covered above. *

Please list all medications you are currently taking (name and dose, if known). *

Please list any allergies (medication, food, or environmental) and the reaction. *

Please list any prior surgeries and approximate dates. *

Do you have a known sensitivity or allergy to benzyl alcohol (a preservative used in compounded medications)? *

Yes No

Your Treatment Considerations

Please select all conditions, preferences, or concerns that matter most to you regarding your treatment with a GLP-1. *

Here’s your first message to your doctor

Please introduce yourself. This is your first message to your doctor.

Your message

Ask any questions you have
List any medical problem you have which was not discussed above
Include anything else you would like the doctor to know

Consent & Agreement

I understand that a licensed healthcare provider will review my information and contact me regarding eligibility. * I have read and agree to the Privacy Policy and Terms of Service. * I have read and agree to the Informed Consent for Telehealth Services. *

You have read this document carefully, and understand the risks and benefits of the telehealth services and have had your questions regarding the services explained and you hereby give your informed consent to participate in a telehealth consultation under the terms described herein.

By typing your name into the appropriate field below for this “INFORMED CONSENT FOR TELEHEALTH SERVICES” you hereby state that you have read, understood, and agree to the terms of this document.

Full legal name *

Fees

Physician consultation fee $20.00

Your $20 consultation fee is included as part of your Strata membership. You will not be charged separately for this consultation.

What happens next:
Your submission will be evaluated for eligibility within 24 to 48 business hours, after which the Strata care team will follow up with your next steps.

GLP-1 Program Application

Personal Information

Date of Birth & Sex

Pregnancy Screening

What is your current height and weight?

Shipping Information

Your Goals & Medication

Medication History

Medical History: GI & Endocrine

Medical History: Kidney

GLP-1 Safety Screening

Lifestyle & Readiness

Medical Background

Your Treatment Considerations

Here’s your first message to your doctor

Consent & Agreement

Application Received