Weight Loss Progress Report

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Please use this form to do your monthly progress report while using weight loss medications.

Email *

Patient Name *

Phone # *

Any new medications prescribed by any other provider? *

Any medical updates to your chart? *

What is your current weight? *

Any side effects or issues you wish to report? *

Do you need a refill of medication? *

Yes

Type of Medication *

Compound Pharmacy

Retail Pharmacy

N/A

Which medication do you need refilled? *

Phentermine

Tirzepatide (Zepbound)

Semaglutide (Wegovy)

Qysmia

Contrave

Lipo-Mino Aminos "MICC"

Other

N/A

Required

Injectable Meds: Which dosing are you at currently?

Semaglutide 0.25mg (10 units)

Semaglutide 0.5mg (20 units)

Semaglutide 1 mg (40 units)

Semaglutide 1.7 mg (68 units)

Semaglutide 2.4mg (96 units)

Tirzepatide 2.5 mg (25 units)

Tirzepatide 5 mg (50 units)

Tirzepatide 7.5 mg (75 units)

Tirzepatide 10 mg ( 100 units)

Tirzepatide 15mg (150 units)

Other

N/A

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Compounded Med: Do you need refill of syringes? *

Yes

N/A

Don't forget to go to the online store and place your next refill order if applicable after submitting your form. Right now Wegovy and Zepbound are on nationwide backorder and there is limited supply available. Southlake is averaging 5-7 business days to ship. Hallandale is running about 3 days to ship.

A copy of your responses will be emailed to the address you provided.

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