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Kairosweightlosswellness Eligibility Questionnaire

Please select the program you are applying for:*

Insurance ProgramCompund Program

Section 2: Eligibility Criteria

I am not pregnant or breastfeeding.
I am not allergic to Semaglutide or Tirzepatide.
I do not have a medical history of thyroid cancer, chronic pancreatitis, gastroparesis, or type 1 diabetes.
My BMI is over 27, and I am considered overweight or obese.
I do not currently have Medicaid, Medicare, Tricare, or Kaiser (this only applies if you selected insurance program)

Please confirm the following statements are true for you to proceed with the application.*

Yes I acknowledge all of this true

I acknowledge that I understand that coverage from my health insurance company is NOT guaranteed. Kairos weightloss wellness. will complete the prior authorization process, but these medications may be a plan exclusion with my health insurance

I acknowledge that medication may be on national backorder. Body Good Studio will do their best to source the medications through their partner pharmacy to fulfill my request.

Please confirm the following statements are true for you to proceed with the application.*

Yes I acknowledge all of this true