{"id":3848,"date":"2025-07-24T19:22:16","date_gmt":"2025-07-24T19:22:16","guid":{"rendered":"https:\/\/my.vitalcore-health.com\/?page_id=3848"},"modified":"2026-03-26T20:33:47","modified_gmt":"2026-03-26T20:33:47","slug":"pre-qualification-form","status":"publish","type":"page","link":"https:\/\/vitalcore.setupwp.io\/en\/pre-qualification-form\/","title":{"rendered":"Pre-Qualification Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3848\" class=\"elementor elementor-3848\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\" data-elementor-post-type=\"page\">\n\t\t\t\t<div data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-element elementor-element-33cab416 e-con-full elementor-hidden-mobile_extra elementor-hidden-mobile e-flex e-con e-parent\" data-id=\"33cab416\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t<div data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-element elementor-element-39f406cf e-con-full e-flex e-con e-child\" data-id=\"39f406cf\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-7f5383d2 elementor-widget elementor-widget-spacer\" data-id=\"7f5383d2\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-element elementor-element-4c7e28e e-flex e-con-boxed e-con e-parent\" data-id=\"4c7e28e\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-e5f29b9 elementor-widget elementor-widget-heading\" data-id=\"e5f29b9\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<p class=\"elementor-heading-title elementor-size-default\"><b>Step 1<\/b>: Pre-qualification Questionnaire<\/p>\t\t\t\t<\/div>\n\t\t<div data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-element elementor-element-901180d e-con-full e-flex e-con e-child\" data-id=\"901180d\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-64f2e3c elementor-widget elementor-widget-text-editor\" data-id=\"64f2e3c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p><strong>You\u2019re here because this hasn\u2019t been easy, and we get that.<\/strong> VitalCore has been built by people who use GLP-1 care and understand the realities of weight and wellness firsthand. If you\u2019re wondering whether this approach could work for you, this quick pre-qualification is the place to start!<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-element elementor-element-c1566f9 e-flex e-con-boxed e-con e-parent\" data-id=\"c1566f9\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-element elementor-element-145c014 e-con-full e-flex e-con e-child\" data-id=\"145c014\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;gradient&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-d161e58 eael-gravity-form-button-custom elementor-widget elementor-widget-eael-gravity-form\" data-id=\"d161e58\" data-element_type=\"widget\" data-e-type=\"widget\" id=\"qual-form\" data-widget_type=\"eael-gravity-form.default\">\n\t\t\t\t\t\t\t\t<div class=\"eael-contact-form eael-gravity-form placeholder-hide eael-custom-radio-checkbox eael-contact-form-align-center\">\n\t\t        <script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context 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gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_9'  action='\/en\/wp-json\/wp\/v2\/pages\/3848#gf_9' data-formid='9' novalidate>\n        <div id='gf_progressbar_wrapper_9' class='gf_progressbar_wrapper' data-start-at-zero='1'>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>3<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_0' style='width:0%;'><span>0%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_9_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_9_63\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_63'><span class='gform-field-label__text'>LinkedIn<\/span><\/label><div class='ginput_container'><input name='input_63' id='input_9_63' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_9_63'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_9_27\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Your Contact Information<\/h3><\/div><div id=\"field_9_59\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_9_59'><span class='gform-field-label__text'>Affiliate ID<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_9_59' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_9_1'>\n                            \n                            <span id='input_9_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_9_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_9_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_9_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_9_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_9_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_9_23\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_9_23_container'>\n                                <span id='input_9_23_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_23' id='input_9_23' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_9_23' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_9_23_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_23_2' id='input_9_23_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_9_23_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_9_24\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_24'><span class='gform-field-label__text'>Phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_24' id='input_9_24' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"    \/><\/div><\/div><fieldset id=\"field_9_40\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Phone Contact Consent<\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_40.1' id='input_9_40_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_9_40\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_40_1' ><span class='gform-field-label__text'>Yes, I agree to the terms outlined below for use of my phone number<\/span><\/label><input type='hidden' name='input_40.2' value='Yes, I agree to the terms outlined below for use of my phone number' class='gform_hidden' \/><input type='hidden' name='input_40.3' value='19' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_9_40'><div class='gfield_consent_description_text' tabindex='0'><span style=\"font-size: 9.7pt;\">By checking this box\/responding Yes, I authorize VitalCore Health and its affiliates to contact me via phone, and\/or text (SMS) at the number I provided using automated dialing technology for prescription notifications, including that my prescription may be due for a refill or expired;marketing; billing, or other financial content.  You are not required to respond \u201cYes!\u201d in order to continue receiving goods or services. Message and data rates may apply. To opt-out at any time reply STOP to any text message or email us at store@vitalcore-health.com.<\/span><\/div><\/div><\/fieldset><div id=\"field_9_60\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_60'><span class='gform-field-label__text'>Name of referring physician\/practitioner (if any):<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_9_60' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <button type='button' id='gform_next_button_9_46' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_2' class='gform_page' data-js='page-field-id-46' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_9_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_9_22\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Pre-qualifying Information<\/h3><\/div><fieldset id=\"field_9_7\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>How old are you as of today?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_7'>\n\t\t\t<div class='gchoice gchoice_9_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='10'  id='choice_9_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_7_0' id='label_9_7_0' class='gform-field-label gform-field-label--type-inline'>18 - 60 years<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='5'  id='choice_9_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_7_1' id='label_9_7_1' class='gform-field-label gform-field-label--type-inline'>61 - 75 years<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_7_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='2'  id='choice_9_7_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_7_2' id='label_9_7_2' class='gform-field-label gform-field-label--type-inline'>Over 75 years<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Have you ever taken a GLP-1 medication or are you currently using one for weight loss?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_12'>\n\t\t\t<div class='gchoice gchoice_9_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='10'  id='choice_9_12_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_9_12\"   \/>\n\t\t\t\t\t<label for='choice_9_12_0' id='label_9_12_0' class='gform-field-label gform-field-label--type-inline'>*Yes, I'm presently taking GLP-1 medications for the purposes of weight loss.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='11'  id='choice_9_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_12_1' id='label_9_12_1' class='gform-field-label gform-field-label--type-inline'>*Yes, I have taken GLP-1 medications for the purposes of weight loss in the past.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_12_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='5'  id='choice_9_12_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_12_2' id='label_9_12_2' class='gform-field-label gform-field-label--type-inline'>No, I am not and have not taken prescription drugs for weight loss.<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_9_12'>*If your assigned medical provider determines that a compounded medication is medically necessary, it will be prepared according to their specific instructions. This may lead to adjustments in your dosage or other variations tailored to your individual health needs. By answering Yes to either statement, I'm agreeing that I understand this possibility for change.<\/div><\/fieldset><div id=\"field_9_4\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_4'><span class='gform-field-label__text'>How tall are you in inches?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_4' id='input_9_4' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_9_4\" \/><\/div><div class='gfield_description' id='gfield_description_9_4'>E.g., 5'5\" would be 65 inches. 6'2\" would be 74 inches.<\/div><\/div><div id=\"field_9_5\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_5'><span class='gform-field-label__text'>What is your current weight in pounds?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_5' id='input_9_5' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_9_58' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_9_58' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_3' class='gform_page' data-js='page-field-id-58' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_9_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_9_47\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Tell Us More About Yourself<\/h3><\/div><fieldset id=\"field_9_48\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-checkbox gfield--width-full vh_list_2col gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>What are your weight and wellness goals?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_9_48'>Check all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_48'><div class='gchoice gchoice_9_48_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.1' type='checkbox'  value='Feel more confident and better about myself'  id='choice_9_48_1'   aria-describedby=\"gfield_description_9_48\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_48_1' id='label_9_48_1' class='gform-field-label gform-field-label--type-inline'>Feel more confident and better about myself<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_48_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.2' type='checkbox'  value='Be healthier overall'  id='choice_9_48_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_48_2' id='label_9_48_2' class='gform-field-label gform-field-label--type-inline'>Be healthier overall<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_48_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.3' type='checkbox'  value='Look great for a special event'  id='choice_9_48_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_48_3' id='label_9_48_3' class='gform-field-label gform-field-label--type-inline'>Look great for a special event<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_48_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.7' type='checkbox'  value='Improve appearance overall'  id='choice_9_48_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_48_4' id='label_9_48_4' class='gform-field-label gform-field-label--type-inline'>Improve appearance overall<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_48_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.6' type='checkbox'  value='Have more energy to keep up with life, family, work, etc.'  id='choice_9_48_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_48_5' id='label_9_48_5' class='gform-field-label gform-field-label--type-inline'>Have more energy to keep up with life, family, work, etc.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_48_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.5' type='checkbox'  value='Create a healthier relationship with food'  id='choice_9_48_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_48_6' id='label_9_48_6' class='gform-field-label gform-field-label--type-inline'>Create a healthier relationship with food<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_48_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.4' type='checkbox'  value='Maintain existing weight loss'  id='choice_9_48_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_48_7' id='label_9_48_7' class='gform-field-label gform-field-label--type-inline'>Maintain existing weight loss<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_48_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.8' type='checkbox'  value='Other'  id='choice_9_48_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_48_8' id='label_9_48_8' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_49\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_9_50\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_50'><span class='gform-field-label__text'>How do you feel about embarking on a healthier lifestyle, including physical activity and better eating habits?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_50' id='input_9_50' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Super Thrilled' >Super Thrilled<\/option><option value='Excited, but nervous' >Excited, but nervous<\/option><option value='I feel ok about it' >I feel ok about it<\/option><option value='Fearful I won&#039;t be able to adapt easily' >Fearful I won&#039;t be able to adapt easily<\/option><option value='Really scared I won&#039;t succeed' >Really scared I won&#039;t succeed<\/option><\/select><\/div><\/div><div id=\"field_9_51\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_9_52\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-checkbox gfield--width-full vh_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>What types of information interest you most?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_52'><div class='gchoice gchoice_9_52_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.1' type='checkbox'  value='Healthy Eating Tips'  id='choice_9_52_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_1' id='label_9_52_1' class='gform-field-label gform-field-label--type-inline'>Healthy Eating Tips<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_52_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.2' type='checkbox'  value='Weight Loss Tips'  id='choice_9_52_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_2' id='label_9_52_2' class='gform-field-label gform-field-label--type-inline'>Weight Loss Tips<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_52_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.3' type='checkbox'  value='Exercise Tips'  id='choice_9_52_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_3' id='label_9_52_3' class='gform-field-label gform-field-label--type-inline'>Exercise Tips<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_52_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.4' type='checkbox'  value='Mental Health &amp; Wellness Info'  id='choice_9_52_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_4' id='label_9_52_4' class='gform-field-label gform-field-label--type-inline'>Mental Health &amp; Wellness Info<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_52_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.5' type='checkbox'  value='General Weight &amp; Wellness Info'  id='choice_9_52_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_5' id='label_9_52_5' class='gform-field-label gform-field-label--type-inline'>General Weight &amp; Wellness Info<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_52_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.6' type='checkbox'  value='Weight Loss Success Stories'  id='choice_9_52_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_6' id='label_9_52_6' class='gform-field-label gform-field-label--type-inline'>Weight Loss Success Stories<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_52_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.7' type='checkbox'  value='Tips for Staying on Track with Your Weight Loss Journey'  id='choice_9_52_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_7' id='label_9_52_7' class='gform-field-label gform-field-label--type-inline'>Tips for Staying on Track with Your Weight Loss Journey<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_52_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.8' type='checkbox'  value='Tips for Maintaining a Healthy Goal Weight'  id='choice_9_52_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_8' id='label_9_52_8' class='gform-field-label gform-field-label--type-inline'>Tips for Maintaining a Healthy Goal Weight<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_52_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.9' type='checkbox'  value='Other'  id='choice_9_52_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_9' id='label_9_52_9' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_53\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_9_54\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_54'><span class='gform-field-label__text'>What is your gender<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_54' id='input_9_54' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Female' >Female<\/option><option value='Male' >Male<\/option><option value='Non-binary \/ Third gender' >Non-binary \/ Third gender<\/option><option value='Prefer Not to Say' >Prefer Not to Say<\/option><\/select><\/div><\/div><div id=\"field_9_55\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_55'><span class='gform-field-label__text'>In what US state do you live?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_55' id='input_9_55' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select><\/div><\/div><div id=\"field_9_37\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Affirmation &amp; Consent<\/h3><\/div><fieldset id=\"field_9_61\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>I agree to VCH&#039;s Privacy Policy and Terms &amp; Conditions.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_9_61'><div class='gfield_consent_description_text' tabindex='0'>I affirm that I have read, understand, and agree to VitalCore Health's <a href=\"https:\/\/my.vitalcore-health.com\/privacy-policy\/\" target=\"_blank\" rel=\"noopener\">Privacy Policy<\/a> and <a href=\"https:\/\/my.vitalcore-health.com\/terms-of-use\/\" target=\"_blank\" rel=\"noopener\">Terms &amp; Conditions<\/a>.<\/div><\/div><div class='ginput_container ginput_container_consent'><input name='input_61.1' id='input_9_61_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_9_61\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_61_1' ><span class='gform-field-label__text'>Yes<\/span><\/label><input type='hidden' name='input_61.2' value='Yes' class='gform_hidden' \/><input type='hidden' name='input_61.3' value='19' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_9_34\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Disclaimer, Drug Safety, and Refund Policy<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_9_34'><div class='gfield_consent_description_text' tabindex='0'>I affirm that I have read and understand\/accept VitalCore Health's <a href=\"https:\/\/my.vitalcore-health.com\/glp1-disclaimer\/\" target=\"_blank\" rel=\"noopener\">Disclaimer<\/a>, <a href=\"https:\/\/my.vitalcore-health.com\/drug-safety-info\/\" target=\"_blank\" rel=\"noopener\">Drug Safety Information<\/a>, and <a href=\"https:\/\/my.vitalcore-health.com\/refund-policy\/\" target=\"_blank\" rel=\"noopener\">Refund Policy<\/a>.<\/div><\/div><div class='ginput_container ginput_container_consent'><input name='input_34.1' id='input_9_34_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_9_34\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_34_1' ><span class='gform-field-label__text'>Yes<\/span><\/label><input type='hidden' name='input_34.2' value='Yes' class='gform_hidden' \/><input type='hidden' name='input_34.3' value='19' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_9_39\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>I affirm that all information I provided in this form is true and accurate to the best of my knowledge and belief.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_9_39'><div class='gfield_consent_description_text' tabindex='0'>I understand that providing false or misleading information may result in disqualification from treatment eligibility and could have legal or medical consequences. <\/div><\/div><div class='ginput_container ginput_container_consent'><input name='input_39.1' id='input_9_39_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_9_39\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_39_1' ><span class='gform-field-label__text'>Yes<\/span><\/label><input type='hidden' name='input_39.2' value='Yes' class='gform_hidden' \/><input type='hidden' name='input_39.3' value='19' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_9_62\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-half field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Email Marketing Consent<\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_9_62'><div class='gfield_consent_description_text' tabindex='0'>I agree to receive marketing emails from VitalCore Health, including product updates, promotions, wellness tips, and other marketing communications. I understand I can unsubscribe at any time and that agreeing is not required to receive services.<\/div><\/div><div class='ginput_container ginput_container_consent'><input name='input_62.1' id='input_9_62_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_9_62\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_62_1' ><span class='gform-field-label__text'>Yes<\/span><\/label><input type='hidden' name='input_62.2' value='Yes' class='gform_hidden' \/><input type='hidden' name='input_62.3' value='19' class='gform_hidden' \/><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><button type='submit' id='gform_previous_button_9' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='submit' id='gform_submit_button_9' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_9' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_9' id='gform_theme_9' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_9' id='gform_style_settings_9' value='' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_9' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='9' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' 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If you think you entered information incorrectly, please check your answers in this form to try again.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Step 1: Pre-qualification Questionnaire You\u2019re here because this hasn\u2019t been easy, and we get that. VitalCore has been built by people who use GLP-1 care and understand the realities of weight and wellness firsthand. If you\u2019re wondering whether this approach could work for you, this quick pre-qualification is the place to start! &quot;*&quot; indicates required [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"_angie_page":false,"footnotes":"","_members_access_role":[],"_members_access_error":""},"folder":[62,61],"class_list":["post-3848","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Pre-Qualification Form | VitalCore Health<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/a0e3d7dd-b077-4bfb-b2fa-7e9a6a88f5ec.cv02.conves.io\/pre-qualification-form\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Pre-Qualification Form | VitalCore Health\" \/>\n<meta property=\"og:description\" content=\"Step 1: Pre-qualification Questionnaire You\u2019re here because this hasn\u2019t been easy, and we get that. 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