GLP-1 Program — Caballero Medical Center

Let's get started

Enter your contact details below. All information is kept confidential.

First Name *

Required

Last Name *

Required

Email Address *

Enter a valid email

Phone Number *

Required

About You

Basic information to help assess your eligibility.

Age Range *

Under 18 18 – 29 30 – 39 40 – 49 50 and older

Please select your age range

Sex at Birth *

Female Male

Please select an option

Parish / Location *

Please select your location

Your Measurements

Height and weight allow us to calculate BMI, which is used in the eligibility assessment.

Weight (lbs) *

Required

Height (inches) *

Required

Tip: To convert height — multiply feet by 12 then add extra inches (5ft 5in = 65 inches). To convert kg to lbs multiply by 2.2.

Your Goals

Help us understand what you hope to achieve.

Primary reason for seeking GLP-1 therapy *

Weight loss Weight loss + metabolic health Blood sugar control Other

Please select a reason

Please describe

Previous weight-loss attempts *

Yes — diet and exercise Yes — medications Yes — both No prior attempts

Please select an option

Health History

Please answer honestly. This information is confidential and is essential for your safety.

Important: Have you ever been diagnosed with any of the following? Select all that apply.

Type 1 Diabetes Medullary thyroid carcinoma Multiple Endocrine Neoplasia syndrome (MEN2) Pancreatitis Gallbladder disease Severe Gastrointestinal Disease (e.g. gastroparesis) Eating disorder (past or present) Kidney Disease Currently Pregnant None of the above

Please select at least one option

Current Medications

For screening purposes only. Select all that apply.

Insulin Sulfonylureas (e.g. glipizide, glyburide) Steroids (long-term) Antipsychotic medications None of the above

Please select at least one option

Are you currently pregnant or breastfeeding? *

Yes No

Please select an option

Diabetes & Insulin

A few more health questions to complete your screening.

Do you have diabetes? *

No Yes — Type 2 Yes — Type 1 Unsure

Please select an option

Are you currently using insulin? *

Yes No

Please select an option

Your Commitment

GLP-1 therapy is a long-term medical commitment. Please read the following carefully.

Are you willing to participate in monthly check-ins and follow medical guidance? *

Yes, I am committed to ongoing follow-up No

Please select an option

Which best describes your expectations? *

I understand this is a medical therapy, not a quick fix I expect rapid weight loss without lifestyle changes

Please select an option

Declaration * I confirm that the information provided is accurate to the best of my knowledge and is submitted for eligibility screening purposes only.

You must confirm this declaration to continue

✓

Screening Complete

You May Be Eligible

Based on your responses, you may qualify for a GLP-1 consultation with a licensed physician at Caballero Medical Center. The next step is to pay for your consultation.

Consultation Fee

$5,000 JMD

One-time consultation fee. Pay now to secure your appointment.

⚕

Physician Review Required

Review Required

Some of your responses require a physician review before we can confirm eligibility. A consultation is the next step — your doctor will review everything in detail.

Consultation Fee

$5,000 JMD

A physician will review your screening during this consultation.

Screening Complete

Not Eligible at This Time

Based on your responses, you are not eligible for a GLP-1 consultation at this time. This does not represent a diagnosis. We welcome you to book a general consultation to discuss other health options.

Call us: +1-876-302-0018

✓

Payment Complete!

Your consultation fee has been received. Our team will contact you within 24 hours with your Google Meet link and appointment time. Please check your email and WhatsApp.

Status✓ Paid — Awaiting Booking

Email—

Reference—

Questions? Call: +1-876-302-0018

🏥

See You at the Office

Your screening has been saved. Please visit Caballero Medical Center to complete your payment of $5,000 JMD. Bring or show us this reference number:

Reference ID—

StatusAwaiting In-Office Payment

Name—

A confirmation has also been sent to your email. Our team will follow up with you.

Call: +1-876-302-0018

Start Your GLP-1Health Journey

Let's get started

About You

Your Measurements

Your Goals

Health History

Current Medications

Diabetes & Insulin

Your Commitment

You May Be Eligible

Consultation Fee

Review Required

Consultation Fee

Not Eligible at This Time

Payment Complete!

See You at the Office

Start Your GLP-1
Health Journey