Getting Started To begin, please tell us a little about yourself. How active are you in your daily life? *Very activeSomewhat activeSedentaryHow would you describe your diet? *Very healthySomewhat healthyNeither healthy nor unhealthyUnhealthyHow long have you had concerns about your weight? *6 months or less6 months to 1 yearMore than 1 yearMore than 3 yearsDo you have any of the following conditions?Heart diseaseLiver diseaseKidney diseaseGastrointestinal diseasePancreatitisGall bladder diseaseRespiratory diseaseEndocrine disorder / hormonal imbalancesEating disorderCondition not listedI do not have any other conditions---------------------------------------Please specify the nature of your heart disease *Please specify the nature of your liver disease *Please specify the nature of your kidney disease *Please specify the nature of your GI disorder *Please provide details about your gall bladder disease *Please specify the nature of your respiratory disease *Please specify the nature of your endocrine disorder *Please specify the nature of your eating disorder *A history of eating disorders can affect which weight-loss treatments are safe and appropriate. This helps our clinical team choose an approach that supports your health without triggering harmful patterns.Please specify your unlisted condition *Are you Diabetic? *Diabetes affects your metabolism and can influence which weight-loss treatments are safe and effective. Knowing your type helps us tailor your plan and ensure proper monitoring and follow-ups throughout your treatment.Yes I have Type 1 DiabetesYes I have Type 2 DiabetesI do not have DiabetesI am not sureDo you suffer from Obstructive Sleep Apnea? *Obstructive sleep apnea is often linked to weight-related health risks. Knowing if you have it helps our clinical team choose safe treatment options and monitor you more closely, as some medications and weight-loss plans may need adjustments for your safety.YesNoDo you have Glaucoma or Retinopathy? *Certain weight-loss medications can affect eye pressure. If you have glaucoma or a history of it, our clinical team must choose treatments that are safe and will not worsen your condition.YesNoDo you suffer from Epilepsy or have history of Seizures? *Some weight-loss medications can lower the seizure threshold or interact with treatments used for epilepsy. Knowing about any past or current seizures helps our clinical team ensure your plan is safe and choose medications that will not increase your risk.YesNoDo you or anyone in your family currently have or have had a history of Medullary Thyroid Cancer? *Certain weight-loss medications can increase the risk of thyroid-related complications. If you or a family member has had medullary thyroid cancer, these treatments may not be safe. This helps us choose the right option for you.YesNoDo you or anyone in your family currently have or have had a history of Multiple Endocrine Neoplasia Type 2? *Certain weight-loss medications, especially GLP-1 treatments, are not safe for people with MEN2 due to an increased risk of thyroid cancer. This question helps us ensure your treatment is safe and appropriate.YesNoHave you had major trauma, significant weight loss, surgeries or hospitalizations in the past 6 months? *Recent trauma, illness, significant weight changes, surgeries, or hospitalizations can impact your overall health and may affect which treatments are safe and appropriate. This information helps the physician identify underlying factors and guide your care responsibly.YesNo---------------------------------------Please specify *Are you currently pregnant, planning a pregnancy or breastfeeding? *Certain weight-loss medications are not safe to use during pregnancy or while breastfeeding, and some should be avoided if you are planning to become pregnant soon. This information helps our clinical team ensure your treatment is safe and medically appropriate for you.YesNoI am not sureHow have you tried to lose weight before?SurgeryExerciseDietingSupplementsLaxatives or diureticsTherapy / CounsellingWeight loss medicationsI have not tried to lose weight prior to this---------------------------------------When and which surgery did you have? *Which weight loss medication and prescription dose have you taken? *Are you currently taking any other medications *Current medications may interact with hair loss treatments or affect their safety. Listing all medications you take helps the physician avoid contraindications and choose the most appropriate treatment for you.YESNO---------------------------------------Please specify *Do you have any known allergies? *Allergies can affect which medications are safe for you.YESNO---------------------------------------Please specify *List the allergen, your reaction, and any treatment received so the physician can ensure safe prescribing.Do you consume alcohol, use tobacco products, or use any recreational drugs?YESNO---------------------------------------Please specify *Which drug and frequency?What is your height? (cm or feet) *What is your current weight? (lbs or kgs) *What is your weight loss goal? *1-20 lbs21-50 lbsMore than 50 lbsAs much as I can to attain a healthy levelWhat was your most recent blood pressure reading? *Must have been taken in the last 12 monthsLow blood pressure (below 90/60)Normal (90/60 to 119/79)Slightly elevated (120–129 / under 80)High blood pressure – Stage 1 (130–139 / 80-89)Very High blood pressure – Stage 2 (140+ / 90+)I’m not sure / I don’t check it regularlyHave you had blood work done in the past two years? *Recent blood work helps our clinical team identify underlying factors—such as thyroid concerns, diabetes risk, or nutritional deficiencies—that may influence your weight or affect which treatments are safe and effective for you. If you have not had blood work within the past two years, the assessing physician may request updated tests based on your screening results. Your Clinical Care Coordinator will assist in arranging any required labs and guide you through the process to ensure a thorough and safe assessment.YESNO---------------------------------------Were there any abnormalities in the report?YESNOI am not surePlease specify *Is there any additional medical information, questions or requests for the doctor that you’d like to include? *Do you have a preference for your weight-loss treatment? *Medication preference does not guarantee approval. Your clinician will recommend and prescribe a treatment only if it is medically appropriate, safe, and clinically indicated based on your assessment.Ozempic (semaglutide): A once-weekly injection that helps control appetite cravings and blood sugar. Starting at $ 349Wegovy (semaglutide): A higher-dose once-weekly semaglutide specifically approved for weight management. Starting at $ 569Mounjaro (tirzepatide): A dual-action once-weekly medication that targets appetite and metabolic regulation. Starting at $ 549Zepbound (tirzepatide): A tirzepatide formulation approved specifically for weight loss taken once weekly. Starting at $ 549I am not sure - I need a consultation registration form Medication counselling?Please select if you would like counselling with a ClinicianGenderMaleFemalePrefer not to sayPlease upload a clear full-body photo for safety and compliance. *Telehealth standard of care - This step helps our clinicians ensure the information you’ve provided matches your profile and supports safe prescribing. Your photo remains private and protected at all times. Your information is encrypted and stored securely under PHIPA and PIPEDA guidelines.Drag and Drop (or) Choose FilesPlease provide a clear photo of your valid Ontario Health Card *Our team uses this only to confirm your identity and ensure you receive any OHIP-covered benefits you may be eligible for. Your information remains private and fully protected.Drag and Drop (or) Choose FilesPlease upload a photo of a valid Ontario government-issued ID (Driver’s License, Photo Card or Passport) *This helps us verify your identity and maintain a safe, compliant clinical process. Your ID is used only for verification and is securely stored under Ontario privacy regulations.Drag and Drop (or) Choose FilesWhat happens next… Once you submit your form, a Clinical Care Coordinator will contact you to verify your information, answer any questions, and confirm the assessment fee. Your care will then move through the following steps: 1. File Preparation - Your coordinator will finalize your file and forward it to the physician for review. 2. Physician Assessment - A licensed Ontario physician will assess your intake and determine if treatment is appropriate. 3. Prescription & Charges - If approved, your prescription will be issued, and medication costs will only be charged after approval. 4. Pharmacy Delivery - Your medication will be dispensed by a licensed Ontario pharmacy and delivered discreetly to your home. 5. Ongoing Support - Your coordinator and physician team will assist with renewals, follow-ups, and any adjustments needed. Fees & Payment Notice .... A CA $89 annual program fee is collected upfront to begin the assessment and is non-refundable once the assessment starts. This fee covers clinical care coordination, assessment processing, ongoing support, free delivery, and discreet packaging. If a prescription is not approved, the annual program is cancelled and a partial refund is issued, with CA $40 retained as an assessment fee. Charges in this case apply only to the completed assessment. A CA $40 follow-up or renewal fee applies per cycle for reassessment and prescription coordination. Medication costs are not included and are billed only if a prescription is approved, with pricing varying by treatment and dosage.Consent - By clicking Submit, you accept our Terms of Use and Privacy Policy, (accessible on www.rumini.ca) and provide consent for Rumini to securely collect and process your information through virtual care. You also confirm that all information provided is true, accurate, and complete to the best of your knowledge.Rigister Get Started First Name: Last Name: Email: Phone Number: Primary Goal Select...Lose 10–25 lbsLose 25–50 lbsLose 50+ lbsImprove metabolic healthMaintain current weight loss Medication Preference Select...MounjaroZepboundOzempicWegovyI do not have any preference