One Family Clinic Sherman - Semaglutide or Tirzepatide Eligibility Quiz

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1. Are you over 18 years old?* This field is required.

Yes

No

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2. Are you currently pregnant or breastfeeding, or planning to become pregnant in the next few months?* This field is required.

Yes

No

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3. Are you currently being treated for cancer?* This field is required.

Yes

No

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4. Do you have history of medullary thyroid cancer or MEN syndrome?* This field is required.

Yes

No

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5. Do you have Active Gallbladder Disease or Type I Diabetes?* This field is required.

Yes

No

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6. Do you have Active Eating Disorder or Substance Dependency/Abuse?* This field is required.

Yes

No

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7. Have you had Pancreatitis within the past 6 months, or a history of Pancreatitis caused by taking a GLP-1 medication?* This field is required.

Yes

No

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8. Have you had Bariatric surgery in the past 18 months?* This field is required.

Yes

No

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9. What is your Weight in Lbs?* This field is required.

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10. What is your Height in Inches?* This field is required. For example: 5 feet 8 inches are 68 inches

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Your BMI is calculated to be:

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Please call One Family Clinic at 903-618-3244 for more information about GLP-1 RAs treatment eligibility.

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It appears that you are eligible to start weight loss treatment with GLP-1 RAs medication! Would you like to make an appointment and get started?* This field is required.

YESNO

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Appointment

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What is Your Name?* This field is required.

First Name

Last Name

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What is Your Phone Number?* This field is required.

Area Code

Phone Number

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What is Your Email Address?* This field is required.

example@example.com

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Do you have any questions for us about our Weight Management program?

YESNO

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We would like to discuss with you about your medical history before we can determine your eligibility. We will contact you as soon as we can.

YESNO