You will NOT be charged until your application has been officially approved by one of our providers. Once you have been approved, myconnectmed.com will charge your card on file accordingly
If you do not meet the requirements, we will reach out to discuss alternative options to assist in your weight loss journey. However, if you don't qualify you will be charged for the initial monthly fee.
At myconnectmed.com we are here to help you achieve your weight loss goals!
GLP-1 Semaglutide or Tirzepatide Prescription Form Agreement
By signing this form, I confirm that all information provided is true, accurate, and complete. I understand that any false or misleading information may result in denial of treatment and potential legal consequences.
I acknowledge that my healthcare provider is relying on the accuracy of my information to determine my eligibility for GLP-1 Semaglutide or Tirzepatide and that I will follow all prescribed instructions. I understand that misuse or misrepresentation may pose health risks and legal liabilities.
I consent to the collection and use of my personal health information in compliance with applicable privacy laws.
By signing below, I affirm that:
I am legally eligible to apply for this prescription.
The provided information is accurate.
I will report any health status changes.
I have read and agree to these terms.
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