Free Health Assessment

Independent physician review within 48 hours · No charge today · Cancel anytime

1
Program
2
Body Stats
3
Medical History
4
Medications
5
Symptoms
6
Consent
7
Contact
Step 1 of 7

Which program are you
interested in?

Select the program that best fits your goals. Your physician will tailor the treatment plan to you.

Please select a program to continue.
Step 2 of 7

Your Body Stats

Used by your physician to determine eligibility and dosing. BMI is calculated automatically.

Please enter your weight.
Step 3 of 7

Medical History

Answer honestly — your physician uses this to prescribe safely. Check all that apply. If none apply, select "None of the above."

Group 1 — Serious Conditions
Group 2 — Metabolic Conditions
Group 3 — Cardiovascular & Other
Group 4 — Additional Conditions
Step 4 of 7

Medications & Health Details

This helps your physician check for drug interactions. Include all prescriptions, OTC, and supplements.

Are you currently taking any prescription medications? *
Please select an option.
Have you previously used GLP-1 medications? *
Please select an option.
Have you tried structured weight loss programs before? *
Please select an option.
Step 5 of 7

Symptoms & Goals

Help your physician understand what you're experiencing and what you're hoping to achieve.

Current symptoms (select all that apply)
Treatment priority *
Please select a priority.
Step 6 of 7

Informed Consent

Please read and acknowledge each item before proceeding. All required items must be checked.

Step 7 of 7

Contact Information

Your physician and our care team will reach you using the information below. All fields required.

Required.
Required.
Valid email required.
Valid phone required.
Must be 18 or older.
Required.
Please select your state.
⚠️ By submitting this form you certify that all information provided is accurate and complete. Providing false information to obtain controlled substances is a federal offense under 21 U.S.C. § 843.
✓

Assessment
Submitted!

Thank you — your health assessment has been received. An independent licensed physician will review your information and you'll hear back within 24 hours. Check your email inbox.

1

Check Your Email

Confirmation sent to the email you provided. Check spam if you don't see it within 5 minutes.

2

Physician Reviews (<24hrs)

An independent licensed physician reviews your assessment and makes a prescribing decision.

3

Receive Approval Email

If approved, you'll receive a secure payment link. No charge until you activate.

4

Medication Ships 3–5 Days

After payment, medication ships from a licensed compounding pharmacy in discreet packaging.

← Return to ProviaRx
ProviaRx is a technology platform only. All prescribing decisions made exclusively by independent licensed physicians. Compounded medications are not FDA-approved. Results vary. This form does not constitute medical advice.
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