Full Name
Date of Birth
Phone Number
Email Address
State of Residence
Height
Weight
Do you have a primary care provider?
Yes No
If yes, name & location
Have you had an A1c test in the past 6 months?
Most recent A1c value
Upload lab report (if available)
Is your A1c ≥ 5.7%? Yes No
If YES, select one: 5.7–5.9% (Prediabetes) 6.0–6.4% (High-risk Prediabetes) ≥ 6.5% (Diabetes)
Has your A1c increased by ≥ 0.5%? Yes No Unsure
Yes (within last 3 months) Yes (longer than 3 months ago) No Unsure
Yes No Already using insulin
Type of insulin (if known)
Current dose (if known)
Yes – Starting soon Yes – Currently taking No
Which medication? Mounjaro Ozempic Wegovy Trulicity Zepbound Other
Current / starting dose
Please upload any relevant labs, medication list, or previous glucose readings
Submit Form
945 Stockton Drive,Ste #6100 Allen, TX 75013
Phone: 972-390-7667
Fax: 972-390-1557
