Weight Loss Questionnaire

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Step 1 of 11

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Doctor's Notes

Let's Get Started

First Name*

Last Name*

Email*

Phone*

Date Of Birth*

Month

Day

Year

Sex*

State*

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We're sorry, but SimpleFixRx is currently not available in your selected state. Please reach out to support@simplefixrx.com. We may still be able to help you get the prescription you are looking for!

Medical History

Have you seen a doctor in the past 12 months?*

No, I have not seen a doctor in the past 12 months.

Yes, I have seen a doctor in the past 12 months.

Your Weight (Lbs)*

Height (Feet)*

Height (Inches)*

Bmi

Weight(Lbs)

Height (feet/inches)

Height (cm)

Have you been diagnosed with any of these conditions?*

High Blood Pressure

Type 2 Diabetes

High Cholesterol

Pulmonary Condition

None

Other

How often do you exercise?*

3-4 days a week

2-3 days a week

Very little

Never

Other

What type of exercise do you do?*

Which of the following weight loss medications have you tried?*

Semaglutide (Wegovy)

Tirzepatide (Mounjaro)

Orlistat (Xenical, Alli)

Phentermine-topiramate (Qsymia)

Naltrexone-bupropion (Contrave)

Liraglutide (Saxenda)

None, I have not tried Rx weight management meds

Have you had serious issues with gallbladder within the past 12 months? *

Pain in your upper stomach (abdomen)

Yellowing of the skin or eyes (jaundice)

Clay-colored stools

I have active Gallbladder Disease

No, I do not have any of these symptoms

Have you been diagnosed with inflammation of your pancreas (pancreatitis) in the past 6 months?

Yes

Have you been diagnosed with kidney disease in the past 12 months? *

Yes

Do you have sleep conditions such as sleep apnea?*

Yes, I have Sleep Apnea

No, I do not have Sleep Apnea

Are you on hormone therapy?*

Creams

Pellet

No, I am not on hormone therapy

Not currently, but I should be

I am happy with my hormone health

In the past 12 months, I...*

Experienced no mental health problems, ie anxiety, depression

I am on medication, but feel in control of my mental health

I deal with stress, but no medication. Some days are stressful, but I feel okay.

Have you ever been diagnosed with medullary thyroid cancer or MEN syndrome?*

Yes

Do you have an active eating disorder?*

Yes

Are you currently pregnant or breastfeeding? Semaglutide cannot be taken while breastfeeding.*

Yes

Are you planning on getting pregnant in the next year?*

Yes

Do you have type 1 diabetes*

Yes

Are you currently struggling with substance abuse or dependency problems?*

Yes

Have you had bariatric surgery within the past 18 months*

Yes

Do you get headaches often?*

Yes

Do you experience chronic pain?*

Yes

Please list current medications. (including any medications you’ve taken in the last 45 days)

Is the any additional medical history our provider should know during the consult?

***Important Notice:

New compliance measures require all new (or) returning patients seeking an increase in their medication to schedule a call with a physician. If you are a new patient, or are seeking an increase in your dose, you will be directed to schedule your online doctor consult immediately following your payment. If answered incorrectly, requested medication could be delayed (or) your order could be canceled and payment refunded. For any question, please contact support@simplefixrx.com

Do you need to schedule a call with the doctor?*

Yes - I am a new patient (or) I am a returning patient seeking an increase in my dose.

No - I am a returning patient requesting the same dose.

Weight Management Rx History

Have you taken any of the following GLP1 weight loss medications?*

Semaglutide

Tirzepatide

Both

None of the above

Did any of the following side effects cause you to discontinue treatment?*

Nausea

Diarrhea

Stomach (abdominal) pain

Vomiting

Constipation

No side effects

Other...

Please specify other side effects caused by taking any GLP1 weight loss medications...*

Did you previously purchase your weight loss medication from SimpleFix?*

Yes

Where did you purchase your weight loss medication from previously?*

What was the ending medication and strength of your previous treatment?*

0.5 mg Semaglutide (approximate)

1.0 mg Semaglutide (approximate)

1.7 mg Semaglutide (approximate)

2.4 mg Semaglutide (approximate)

5 mg Tirzepatide (approximate)

7.5 mg Tirzepatide (approximate)

10 mg Tirzepatide (approximate)

12.5 mg Tirzepatide (approximate)

15 mg Tirzepatide (approximate)

Unknown

What was your most recent medication/dosage strength?*

0.5 mg Semaglutide

1.0 mg Semaglutide

1.7 mg Semaglutide

2.4 mg Semaglutide

5 mg Tirzepatide

7.5 mg Tirzepatide

10 mg Tirzepatide

12.5 mg Tirzepatide

15 mg Tirzepatide

Would you like the strength of your prescription increased?*

Yes, I'm having a slow or plateau in weight loss and would like to increase the strength of my prescription according to protocol.

No, I'm happy with the amount I'm losing and do not wish to increase the strength of my prescription.

Have you lost muscle and would like the physician to help retain muscle while losing fat?*

Yes

Have GLP 1 products made you feel lethargic?*

Yes

Have you had gastrointestinal issues or nausea while on GLP1 medications?*

Yes

READ OUR TERMS & CONDITIONS POLICY

TELEMEDICINE PATIENT CONSENT PURPOSE:

The purpose of "Telemedicine Consent Form" is to get the patient's consent in order to participate in appointments of telemedicine cares.

RECORDS: Telecommunications with patients will not be recorded and stored. Patients' medical information obtained by the diagnosis and analysis can be used anonymously for further improvements in scientific studies. TELEMEDICINE INFORMATION: The medical information related to history, records and tests of the patient will be discussed during the telemedicine appointment with video and audio.

ACCESS: The patient accepts that he/she needs access to PC, laptop, or mobile device and a good internet connection in order to have an efficient telemedicine appointment. PATIENT RIGHTS: The patient can withdraw his/her consent at any time and can ask the questions related to telemedicine appointments and technical requirements for telecommunication. By signing this form, I understand that all the laws that are protecting my privacy of medical history or information are also applied to telemedicine practices. I understand that I can withdraw the consent at any time and that will not affect any of my future treatment procedures. I understand that I can be charged the additional fees that my insurance does not cover. I accept that I authorize health care professionals and use telemedicine for my treatment and diagnosis.

I agree to terms and conditions*

I agree to terms and conditions

By using SimpleFix you are consenting to the practices described in the privacy policy*

By using SimpleFix you are consenting to the practices described in the privacy policy

Sign & Consent

By signing here, you agree that you have read HIPAA, telemedicine consent, Disclosure and agree that you are the individual in DL and Photo. SimpleFix wlc uses M&D Integrations, Inc for medical decisions and patient care.

Sign here*

Shipping & Billing Information

Shipping Address*

Street Address Address Line 2 City State ZIP Code

Billing Address*

Same as Shipping Address

Street Address Address Line 2 City State ZIP Code

Requested Rx

Important Update on Tirzepatide

Tirzepatide is no longer on the FDA shortage list and is now commercially available. Due to this, compounded Tirzepatide is no longer permitted.

For Existing Patients:

If you’ve been successfully using Tirzepatide and wish to continue your treatment, we can still help you get the prescription you need. Contact us at support@simplefixrx.com or text 682-245-2031, and our team will guide you through your options.

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Pharmacy Routing - Luxe Med

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Pharmacy Routing - Elysium Pharmaceuticals

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Pharmacy Routing - Red Rock Springville

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Pharmacy Routing - Red Rock St George

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Pharmacy Routing - RxCompound Store - Ship Direct

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Pharmacy Routing - RxCompound Store - Ship Oklahoma

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Pharmacy Routing - Specialty Rx Care

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Product Options - Elysium Pharmaceuticals*

2 mg / 0.5 mg Weekly Semaglutide - $300 4 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes

4 mg / 1.0 mg Weekly Semaglutide - $350 4 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes

6 mg / 1.5 mg Weekly Semaglutide - $375 4 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes

10 mg / 2.5 mg Weekly Semaglutide - $400 4 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes

Semaglutide Starter Package - $595 2 mg + 2 mg + 4 mg (3-Month Supply)

Semaglutide Performance Package - $795 4 mg + 6 mg + 10 mg (3-Month Supply)

Semaglutide Max Package - $895 10 mg + 10 mg + 10 mg (3-Month Supply)

10 mg per ml, 2ml vial, 20 mg total / 5 mg Weekly Tirzepatide - $390 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes

15 mg per ml, 2ml vial, 30 mg total / 7.5 mg Weekly Tirzepatide - $450 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes

20 mg per ml, 2ml vial, 40 mg total / 10 mg Weekly Tirzepatide - $525 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes

25 mg per ml, 2ml vial, 50 mg total / 12.5 mg Weekly Tirzepatide - $550 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes

30 mg per ml, 2ml vial, 60 mg total / 15 mg Weekly Tirzepatide - $625 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes

Tirzepatide Starter Package - $795 10 mg/ml + 10 mg/ml + 15 mg/ml (3-Month Supply)

Tirzepatide Performance Package - $1250 20 mg/ml + 25 mg/ml + 30 mg/ml (3-Month Supply)

Tirzepatide Max Package - $1450 30 mg/ml + 30 mg/ml + 30 mg/ml (3-Month Supply)

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Product Options - Red Rock*

0.5 mg Semaglutide - $300 4 Injections, 4-Week Supply, Single-Pack Syringes

1.0 mg Semaglutide - $350 4 Injections, 4-Week Supply, Single-Pack Syringes

1.0 mg Semaglutide - $795 4 Injections, 4-Week Supply, Single-Pack Syringes (2 refills)

1.7 mg Semaglutide - $375 4 Injections, 4-Week Supply, Single-Pack Syringes

2.4 mg Semaglutide - $400 4 Injections, 4-Week Supply, Single-Pack Syringes

2.4 mg Semaglutide - $995 4 Injections, 4-Week Supply, Single-Pack Syringes (2 refills)

4.25 mg Tirzepatide - $390 4 Injections, 4-Week Supply, Single-Pack Syringes

6.375 mg Tirzepatide - $450 4 Injections, 4-Week Supply, Single-Pack Syringes

8.5 mg Tirzepatide - $525 4 Injections, 4-Week Supply, Single-Pack Syringes

11 mg Tirzepatide - $550 4 Injections, 4-Week Supply, Single-Pack Syringes

13.5 mg Tirzepatide - $625 4 Injections, 4-Week Supply, Single-Pack Syringes

Product Options - RxCompound Store*

2 mg / 0.5 mg Weekly Semaglutide - $300 Sema2.5mg/ml 1mL vial + Single-Pack Syringes

4 mg / 1.0 mg Weekly Semaglutide - $350 Sema2.5mg/ml 2mL vial + Single-Pack Syringes

6 mg / 1.5 mg Weekly Semaglutide - $375 Sema2.5mg/ml 3mL vial + Single-Pack Syringes

10 mg / 2.5 mg Weekly Semaglutide - $400 Sema2.5mg/ml 2 x 2mL vial + Single-Pack Syringes

Semaglutide Starter Package - $595 Sema2.5mg/ml 3mL + 0.5mL vials + Double-Pack Syringes (12-Week Supply)

Semaglutide Performance Package - $795 Sema2.5mg/ml 5mL + 3mL vials + Double-Pack Syringes (12-Week Supply)

Semaglutide Max Package - $895 Sema2.5mg/ml 4 x 3mL vial + 2 Single-Pack Syringes (12-Week Supply)

5 mg Weekly Tirzepatide - $390 Tirz10mg/ml 2mL vial + Single-Pack Syringes

7.5 mg Weekly Tirzepatide - $450 Tirz10mg/ml 3mL vial + Single-Pack Syringes

10 mg Weekly Tirzepatide - $525 Tirz10mg/ml 2x2mL vial + Single-Pack Syringes

12.5 mg Weekly Tirzepatide - $550 Tirz10mg/ml 5mL vial + Single-Pack Syringes

15 mg Weekly Tirzepatide - $625 Tirz15mg/ml 2x2mL vial + Single-Pack Syringes

Tirzepatide Starter Package - $795 Tirz10mg/ml 5mL + 2mL vials + Double-Pack Syringes (12-Week Supply)

Tirzepatide Performance Package - $1250 Tirz15mg/ml 2x5mL vials + Double-Pack Syringes (12-Week Supply)

Tirzepatide Max Package - $1450 Tirz15mg/ml 4 x 3mL vial + 2 Single-Pack Syringes (12-Week Supply)

Product Options - Specialty Rx Care*

2 mg / 0.5 mg Weekly Semaglutide - $300 4 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes

4 mg / 1.0 mg Weekly Semaglutide - $350 4 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes

6 mg / 1.5 mg Weekly Semaglutide - $375 4 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes

10 mg / 2.5 mg Weekly Semaglutide - $400 4 Injections, 4-Week Supply, 1x 1ml Vial + Single-Pack Syringes

Semaglutide Starter Package - $595 2 mg + 2 mg + 4 mg (12-week supply dispensed monthly)

Semaglutide Performance Package - $795 4 mg + 6 mg + 10 mg (12-week supply dispensed monthly)

Semaglutide Max Package - $895 10 mg + 10 mg + 10 mg (12-week supply dispensed monthly)

10 mg per ml, 2ml vial, 20 mg total / 5 mg Weekly Tirzepatide - $390 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes

15 mg per ml, 2ml vial, 30 mg total / 7.5 mg Weekly Tirzepatide - $450 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes

20 mg per ml, 2ml vial, 40 mg total / 10 mg Weekly Tirzepatide - $525 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes

25 mg per ml, 2ml vial, 50 mg total / 12.5 mg Weekly Tirzepatide - $550 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes

30 mg per ml, 2ml vial, 60 mg total / 15 mg Weekly Tirzepatide - $625 4 Injections, 4-Week Supply, 1x 2ml Vial + Single-Pack Syringes

Tirzepatide Starter Package - $795 10 mg/ml + 10 mg/ml + 15 mg/ml (12-week supply dispensed monthly)

Tirzepatide Performance Package - $1250 20 mg/ml + 25 mg/ml + 30 mg/ml (12-week supply dispensed monthly)

Tirzepatide Max Package - $1450 30 mg/ml + 30 mg/ml + 30 mg/ml (12-week supply dispensed monthly)

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Product Options - Luxe*

0.5 mg Semaglutide - $300 4 Injections, 4-Week Supply, 1x 3ml Vial + Single-Pack Syringes

1.0 mg Semaglutide - $350 4 Injections, 4-Week Supply, 1x 3ml Vial + Single-Pack Syringes

1.0 mg Semaglutide - $795 12 Injections, 12-Week Supply, 3x 3ml Vials + Double-Pack Syringes

1.7 mg Semaglutide - $375 4 Injections, 4-Week Supply, 1x 3ml Vial + Single-Pack Syringes

2.4 mg Semaglutide - $400 4 Injections, 4-Week Supply, 1x 3ml Vial + Single-Pack Syringes

2.4 mg Semaglutide - $995 12 Injections, 12-Week Supply, 3x 3ml Vials + Double-Pack Syringes

5 mg Tirzepatide - $390 4 Injections, 4-Week Supply, 1x 3ml Vial + Single-Pack Syringes

5 mg/15 mg Tirzepatide - $795 12 Injections, 12-Week Supply, 1x 3ml Vial + Double-Pack Syringes

7.5 mg Tirzepatide - $450 4 Injections, 4-Week Supply, 1x 3ml Vial + Single-Pack Syringes

10 mg Tirzepatide - $525 4 Injections, 4-Week Supply, 1x 3ml Vial + Single-Pack Syringes

12.5 mg Tirzepatide - $550 4 Injections, 4-Week Supply, 1x 3ml Vial + Single-Pack Syringes

15 mg Tirzepatide - $625 4 Injections, 4-Week Supply, 1x 3ml Vial + Single-Pack Syringes

5 mg/15 mg Tirzepatide - $795 12 Injections, 12-Week Supply, 1x 3ml Vial + Double-Pack Syringes

Available Add-ons (Optional)

Anti-Nausea Medication

4 mg Ondansetron - $30 Anti-Nausea Pills, 30-Count

Quantity - Hydration Honey PM Moisturizer

Hydration Honey PM Moisturizer

Price:

Crafted in small batches from all-natural products. This is unlike any skincare on the market. Beeswax locks in moisture while preventing acne due to its natural antibacterial and antifungal properties. Propolis also locks in moisture and is used for wound healing in Europe. You will see a difference in your skin after you sleep in this!

Instructions: Use nightly or as needed.

*Use at night. Rub everywhere. Yes, we said it...Everywhere. Feel amazing in the morning.

60 ml

Ingredients: Beeswax, Propolis, Vitamin A, Cermides, Glycolic acid, Lactic acids, Salicylic acid, Hyaluronic Acid, Lavendar oil, Olive Oil, Shea Butter, Silica

Quantity - Royal Hive Anti-Aging Body Oil

Royal Hive Anti-Aging Body Oil

Price:

This luxurious body oil can double as a perfume. Only all-natural oils with a heavenly scent will soothe the skin, leaving you feeling like royalty for hours and hours. Created with:

Vitamin E, almond oil, olive oil, castor oil, and fragrance.

Size Options*

Quantity - Royal Hive Daily Moisturize with Zinc Oxide

Royal Hive Daily Moisturize with Zinc Oxide

Price:

Beeswax, salicylic acid, hyaluronic acid, vitamin E, shea butter, glycolic acid, lactic acid, propolis, olive oil, ceramides, vitamin C, ferulic acid, and zinc oxide (mineral sunscreen).

Quantity - Royal Honeycomb Body and Hair Smoothing Balm

Royal Honeycomb Body and Hair Smoothing Balm

Price:

A hair balm made from Shea Butter, Almond Oil, Beeswax, and Signature Royal Hive Fragrance.

Quantity - Anti Acne Facial Polish

Anti Acne Facial Polish

Price:

All-natural facial soap that comes in a mesh hanging bag. Keep the product in the mesh even when using (it helps create lather and keeps it clean!). If you want clear skin with zero chemicals, then this product is for you.

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Quantity - Hydration Honey Decolletage

Hydration Honey Decolletage

DISCONTINUED - Hydration Honey Decolletage* Face, neck, chest

Price:

Crafted in small batches from all natural products. This is unlike any skincare on the market. Beeswax locks in moisture while preventing acne due to it's natural antibacterial, antifungal properties. We promise this is unlike other skincare product!

Instructions: Use nightly or as needed.

*Use at night. Rub everywhere. Yes, we said it...Everywhere. Feel amazing in the morning.

60 ml

Ingredients: Beeswax, Propolis, Vitamin A, Cermides, Glycolic acid, Lactic acids, Salicylic acid, Hyaluronic Acid, Lavendar oil, Olive Oil, Shea Butter, Silica

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Quantity - Hydration Honey Body

Hydration Honey Body

DISCONTINUED - Hydration Honey Body

Price:

Use at night. Rub everywhere. Yes, we said it...Everywhere. Feel amazing in the morning.

120ml

Ingredients: Beeswax, Propolis, Vitamin A, Cermides, Glycolic Acid, Lactic Acids, Salicylic Acid, Hyaluronic Acid, Lavendar oil, Olive Oil, Shea Butter, Silica

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Quantity - Blending Nectar Foundation

Blending Nectar Foundation

DISCONTINUED - Blending Nectar Foundation

Price:

Skincare in a makeup? Yes, exactly! This combo has all the acids, sunscreen, silica (no caking) plus mineral color. You can thank us later!

15ml Jar with cosmetic spatula

Colors: Light/Med, Med Dark, Dark

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Color Selection*

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Quantity - Blending Nectar Tinted SPF Liquid

Blending Nectar Tinted SPF Liquid

DISCONTINUED - Blending Nectar Tinted SPF Liquid

Price:

Guys, this one is for you too! Natural mineral sunscreen SPF 30, silica (no caking) plus mineral color. Available in 3 shades. You can thank us later!

15ml Jar with cosmetic spatula

Colors: Light/Med, Med Dark, Dark

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Color Selection*

Shipping Options

Please allow 4 days (48 hours for the physician, 48 hours for the pharmacy) to review and process your order.

Shipping*

Standard Shipping

Standard Shipping with Insurance

SimpleFixRx is not liable for packages lost or stolen during transit. Once your order is handed over to the carrier, both the carrier and you are responsible for the package. To ensure your package during transit, please select the second shipping option, which includes insurance for an extra $10.

Complete Your Payment

Have a Promo Code?

Total

Credit Card*

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number

Expiration Date Month Year

Security Code Cardholder Name

How did you learn about SimpleFix?

Semaglutide Weight Loss Support Facebook Group

Bariatric Surgery Facebook Group

Semaglutide 5 min chat Facebook Group

Instagram/ TikTok/ Facebook

Radio

Other

Still on your weight loss journey? We’re right here with you. Learn More >

Still on your weight loss journey? We’re right here with you. Learn More

Weight Loss Questionnaire

Let's Get Started

SimpleFixRx is Currently Not Available in Your State

Medical History

***Important Notice:

Weight Management Rx History

READ OUR TERMS & CONDITIONS POLICY

Sign & Consent

By signing here, you agree that you have read HIPAA, telemedicine consent, Disclosure and agree that you are the individual in DL and Photo. SimpleFix wlc uses M&D Integrations, Inc for medical decisions and patient care.

Shipping & Billing Information

Requested Rx

Important Update on Tirzepatide

For Existing Patients:

Available Add-ons (Optional)

Hydration Honey PM Moisturizer

Royal Hive Anti-Aging Body Oil

Royal Hive Daily Moisturize with Zinc Oxide

Royal Honeycomb Body and Hair Smoothing Balm

Anti Acne Facial Polish

Hydration Honey Decolletage

Hydration Honey Body

Blending Nectar Foundation

Blending Nectar Tinted SPF Liquid

Shipping Options

Please allow 4 days (48 hours for the physician, 48 hours for the pharmacy) to review and process your order.

Complete Your Payment

Weight Loss Questionnaire

Let's Get Started

SimpleFixRx is Currently Not Available in Your State

Medical History

***Important Notice:

Weight Management Rx History

READ OUR TERMS & CONDITIONS POLICY

Sign & Consent

By signing here, you agree that you have read HIPAA, telemedicine consent, Disclosure and agree that you are the individual in DL and Photo. SimpleFix wlc uses M&D Integrations, Inc for medical decisions and patient care.

Shipping & Billing Information

Requested Rx

Important Update on Tirzepatide

For Existing Patients:

Available Add-ons (Optional)

Hydration Honey PM Moisturizer

Royal Hive Anti-Aging Body Oil

Royal Hive Daily Moisturize with Zinc Oxide

Royal Honeycomb Body and Hair Smoothing Balm

Anti Acne Facial Polish

Hydration Honey Decolletage

Hydration Honey Body

Blending Nectar Foundation

Blending Nectar Tinted SPF Liquid

Shipping Options

Please allow 4 days (48 hours for the physician, 48 hours for the pharmacy) to review and process your order.

Complete Your Payment

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