First Time Questionnaire

Please read the following information prior to completing this form.

Please fill out this form to request eligibility for the program. You will not be able to participate in the program or seek reimbursement for GLP-1 drugs without having first completed this form and having been approved.
Submission will be reviewed and you will be notified of a decision within 3 days.
Once you have received approval email, you will be able to start using your credit toward the purchase of GLP-1 drugs.