Follow-up Weight Loss Visit
Follow-up weight loss
Email address *
Today's date *
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DEMOGRAPHICS
Please complete all sections. Missing information may cause delays in your virtual appointment or you may be asked to reschedule your appointment.
First name, last name *
Your answer
Date of birth *
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Address (Street, City, State, Zip) *
Your answer
Phone number (with area code) *
Your answer
Today's weight (lbs) *
Your answer
What pharmacy do you use? Address? Phone? *
Incorrect or missing information will result in delays with receiving your medication.
Your answer
MEDICAL HISTORY
When was your last menstrual period?
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What medications are you taking? *
Your answer
What allergies do you have? *
Your answer
What medical conditions do you have? *
Your answer
What surgeries have you had? *
Your answer
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