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Welcome to your Weight Loss Journey

Welcome to the beginning of your Weight Loss Journey. Congratulations in advance! Before we proceed, please enter your email address below:

Do you have an existing account with Lasting Cofidence?

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User email:

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Thank you for your email address! There are 3 steps for you to complete before you can secure your monthly subscription. We will now check the system to see where you are in the process and we will load the results below...

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Step1: Medical Compatibility Form & Waiver

We will be asking you a series of questions to gather your information and assess whether the medication is compatible with you. As important as your business is, you are more important to us and we want to make sure that the medication has the best chance of providing the desired results to your weight loss journey. 

Please scroll below to answer each question, mind the prompts when they appear, and make sure to fill as many of the fields as possible especially the ones marked in RED since they are required fields. If you have any questions or concerns, please reach out to us using the chat box. 

User email:

User email:

Your record on the system has the following incompatibility error:

Please re-confirm your response to:

There was an unfortunate error. Please contact us using the chatbox at the lower right corner of the screen.

Birth Day *

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Height

Weight (lbs)

BMI

Are you pregnant or are you trying to become pregnant?
Do you really have or have had
Do you still have cancer?
Have you ever been diagnosed with Anorexia?
Are you currently taking diuretics?
Do you have history of allergy to semaglutide or other glp-1?

User email:

User email:

It seems that you've already filled this form out before. Do you want to update your information?

There was an unfortunate error. Please contact us using the chatbox at the lower right corner of the screen.

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Semaglutide & Tirzepatide

a.k.a Ozempic & Mounjaro (GLP -1 Agonist)

Compatibility Form & Waiver

Please enter your phone number one number at a time starting from the area code. For example: 321 456 7891, don't worry about adding spaces. No need to add the country code (+1) either.

Gender

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Birth Day *

*Age was populated using your Birthday.

We've cleared your previous response so you can put new ones in.

We've cleared your previous response so you can put new ones in.

Error: Incomplete Address| Please select one of the suggested addresses or enter a complete address.

Height

Weight

BMI

We've cleared your previous response so you can put new ones in.

Weight History

When did you become overweight?
Did you ever gain more than 20 pounds in less than 3 months?

How much did you weigh...

Triggers for your weight gain (check all that apply):
Previous weight-loss programs (check all that apply):
Have you ever taken any of these medications? (check all that apply):
Did it work?

Medical History

Do you exercise?
Are you pregnant or are you trying to become pregnant?

We've cleared your previous response so you can put new ones in.

Do you feel rested in the morning?
Please check if you are or have had any of the following (check all that apply):

We've cleared your previous response so you can put new ones in.

Do you still have cancer?

We've cleared your previous response so you can put new ones in.

Have you ever been diagnosed with an eating disorder?
Is it anorexia?

We've cleared your previous response so you can put new ones in.

Are you currently taking diuretics?

We've cleared your previous response so you can put new ones in.

Past surgical history (check all that apply):
Are you currently taking any medication?
Do you have history of allergy to semaglutide or other glp-1?

We've cleared your previous response so you can put new ones in.

Do you have allergies?

Patient Waiver Acknowledgement and Signature

Patient Signature

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Patient Full Name

Complete all necessary fields before you can submit.

An error occurred. Please check if you've filled out all necessary fields above, if so, then please message us through chat or email us at lastingconfidence@gmail.com.

Your responses were successfully submitted, please allow us a moment to redirect.

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If the redirect fails, click the button below:

Eligibility:

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SCROLL UP TO REVIEW YOUR ANSWERS.

Compatibility Form & Waiver Help

Have you submitted yet?

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Step2: Set Up Your Account

The account that you are about to set up is your account within Lasting Confidence. So, that you can login and check your account anytime you need. We already have your email address in the system and we simply need you to enter your password to create your account. If you have any questions or concerns, please reach out to us using the chat box. 

If you already have an account with us, then you may click "Skip this Step".

Please set up a password with your email:

Please set up an account with your email:

Medical Communications opt in

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Your password should have:

  • At least one uppercase letter (A-Z).

  • At least one lowercase letter (a-z).

  • At least one digit (0-9).

  • At least one special character from the set @$!%*?&.

  • Minimum length of 6 characters.

Step 3: Semaglutide Checkout

This is the last and most important step. Please scroll below to find the check out portal, should the portal fail to load on the page, kindly click the orange button to access the portal from a different URL. 

After you're done with this step, you may already leave the page as you will have completed all the steps. If you have any questions or concerns, please reach out to us using the chat box. 

The checkout portal will load below, if it fails to load please click on the button.

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