GET STARTED | My Easy Weight Loss

Let's get started! Are you a NEW or RETURNING patient?

NEW - This is my first time ordering.

RETURNING - I am here to order again.

We are only prescribing and taking patients in the state of Texas and Utah. Do you live in one of these states?

Yes

No

First name

Last name

Email

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Sex at birth

Birthday

Month

Day

Year

Are you pregnant? or planning to become pregnant?

Yes

No

Do you have diabetes?

Yes

No

Have you have a thyroid tumor or M.E.N. Type 2?

Yes

No

Have you ever had pancreatitis?

Yes

No

Please list any other medical condtions: ( N/A if none)

Please list all medications you are currently taking:

List any allergies, if not, write N/A below:

Have you ever taken a GLP-1 medication?

Yes

No

If you taken a GLP-1 medication, please the name, the dosage and the last date you took the medication.

What is current weight?

What is your current height?

Please upload your driver's license

How did you hear about "My Easy Weight Loss?'

By checking here, I certify that I have responded to the questions on this form truthfully. Once your medical history has been evaluated, our team will get back to you through email with a payment link if you qualify. If you don't qualify for the medication, we will email. you as well.

By checking this box, I give consent for medical treatment.

Semaglutide vs. Tirzepatide?

Please review on other locations on this website.

Semaglutide Option 1:

Semaglutide compounded with Glycine. Glycine is an amino acid that may help maintain muscle mass.

Semaglutide- Option 1

0.25 mg Semaglutide+ Glycine (Starting dose)$190

0.5 mg Semaglutide+ Glycine$190

1.0 mg Semaglutide+ Glycine$200

1.5 mg Semaglutide +Glycine$230

2..0 mg Semaglutide+ Glycine$230

2.5 mg Semaglutide+ Glycine$280

Tirzepatide-- Option2:

Tirzepatide compounded with Vitamin B6 which may help improve comfort and energy levels.

Tirzepatide compounded with B12

After this form is submitted, and Dr. Kempton has approved your order. we will send a Quickbooks payment link from Montgomery Primary Care. (It is not necessary to have Quickbooks to make a payment.) It is super easy! Once payment is received, we will place your order with the pharmacy. Please note that because Tirzepatide is on the shortage list, and fewer pharmacies are compounded the medication, our pharmacy is overwhelmed. Please allow 10 days to receive your medication after payment is received. Thank you! Dr. K

MY EASY WEIGHT LOSS

START YOUR WEIGHT LOSS JOURNEY

Semaglutide vs. Tirzepatide?

Semaglutide Option 1:

Semaglutide compounded with Glycine. Glycine is an amino acid that may help maintain muscle mass.

Tirzepatide-- Option2:

Tirzepatide compounded with Vitamin B6 which may help improve comfort and energy levels.