Skip The Sick. 🔒 We guarantee 100% privacy. Your information will not be shared with anyone. Get Ready to Lose Weight With Zepbound™ Step 1 of 3 33% Ready to See If Zepbound™ Is Right for You? Patient Information Takes Under 2 MinutesPatient Name* First Last Patient Email* Patient Phone*Terms & Consent* I agree to the Terms & Telehealth Consent Date of Birth using this format: (MM/DD/YYYY)* Month Day Year Gender*Select GenderMaleFemalePatient Height*Patient Weight (in pounds)*State (Select Texas OR Florida)*TXFLAllergies to Medications (if no known allergies to medications, type "NONE")* Let's Gather Your Medical History _________________________________________Medical History Checklist. Check ALL that apply.* Type 2 Diabetes High Blood Pressure High Cholesterol History of Thyroid Cancer or MEN2 History of Pancreatitis Gallbladder Disease Pregnancy or Breastfeeding Major Kidney or Liver Disease Other None of These Current Medications You Are Taking*Have you ever taken Zepbound™ (tirzepatide) or any other GLP-1 agonist?* Yes No I understand that my Zepbound™, if prescribed, will be prepared, billed separately, and delivered by LillyDIrect Pharmacy.* Yes I understand that my Joe Pill™ telemedicine visit is $99 and provides a 3 month supply of Zepbound™, if approved.* Yes I understand that to maintain eligibility for this discounted price on refills, I must complete my refill purchase within 45 days of the delivery or receipt date of my previous Zepbound™ vial prescription.* Yes I understand I must complete follow-up visits at least every 3 months to continue.* Yes _________________________________________ Your Billing AddressBilling Address* Street Address Address Line 2 (optional) City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your billing address the same as your shipping address?* Yes No Shipping Address* Street Address Address Line 2 (optional) City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Texas ZIP Code How did you hear about Joe Pill®?* Search engine (Google/Yahoo/Etc) Facebook/Instagram Tiktok Recommended by friend/colleague Provider Consultation FeeTotal $0.00 Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Expiration Date Security Code Cardholder Name After hitting SUBMIT below, a Joe Pill© affiliated telemedicine provider will review your submission and contact you by phone within 24 hours. Upon prescriber approval, LillyDirect™ will contact you for product payment and shipping.
