Rise Weight Loss Program Application

Please read carefully and enter information below for our medical team to review for our programs with the prescription medication Tirzepatide. If you'd like more information regarding our programs, click here!

We currently prescribe to patients in Utah, Idaho, Colorado, Washington, Nevada, Arizona, New York and Oregon.

We can also provide service to patients who will be available to see us in person at Rise.

Full Name*

First NameLast Name

Gender:*

DOB:*

Date of Birth

Email Address*

example@example.com

Phone Number*

Please enter a valid phone number.

Shipping Address*

Street Address

Street Address Line 2

CityState

Zip Code

Agreements - please read carefully:*

I agree to be contacted by phone/email about the program. A licensed medical professional will review my health history to determine candidacy.I will schedule my initial consultation with Rise Medical Provider after submission.I understand cancellation of either program within 60 days of most previous refill will result in a medical provider fee equivalent to the remaining days of management for the refill.I understand missing appointments or cancelling within 48 hours of a scheduled visit will result in a non-refundable, non-transferable fee of $50 per service scheduled.

Rise Introductory Weight Loss Program: Choose this monthly option if you are looking to lose 5-10 pounds per month. If weight loss is your primary goal, this is the program for you! 100% success rate! Includes Rise Wellness Guide, direct access to medical providers at Rise, medication, supplies and everything needed to be successful in reaching your goals!

Rise Microdosing Program: Choose this monthly option if you are looking to optimize your health with a microdosing plan aimed at reducing inflammation, improving metabolism, and managing weight and appetite utilizing smaller doses. The ultimate health optimizer! Includes Rise Wellness Guide, direct access to medical providers at Rise, medication, supplies and everything needed to be successful in reaching your goals!

Select your program choice:*

Rise Intro

$500.00

Rise Micro

$300.00

Enter coupon

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

All medications prescribed as part of this program require approval by a licensed healthcare professional at Rise after a thorough evaluation. By participating, you acknowledge that individual results may vary and that no specific outcome is guaranteed.

Your personal and health information will be handled in compliance with our Privacy Policy, and you consent to its use for program purposes only. Payments made for this program are refundable for patients who are not candidates for the Rise program selected. No refunds made for services rendered.

Patients without a clinically significant reason to receive the compounded version of tirzepatide, we will prescribe the brand name/commercial option.

By submitting this form, you agree to these terms and acknowledge that you have read and understood this disclaimer.