Full Name
Date of birth
Phone
*
Email
*
Current weight loss medication you are taking
*
Current dose
*
Date of your last dose taken
*
Current weight (lbs)
*
Have you experienced any of the following since your last dose? (Check all that apply)
*
Constipation
Diarrhea
Nausea
Vomiting
Reflux/Heartburn
Abdominal Pain
Other Symptoms
None of the above
If yes, please describe or note how severe these symptoms have been:
Would you like a refill on your anti-nausea medicine (Zofran)?
Yes
No
How would you like to proceed with your next dose?
*
Remain at the same dose
Increase dose
Decrease dose
Unsure- please contact me
Would you like our office to contact you with any questions or concerns before processing your refill?
*
Yes
No
Please confirm that you are ready to place your refill order and process payment.
*
Yes, I'm ready to order and pay for my refill.
Acknowledgment
*
By submitting this form, I confirm that the above information is accurate to the best of my knowledge and that I am an established patient under active treatment with Hello Lovely Esthetique. I also acknowledge that the office will charge my card on file for payment of my medication once my refill has been authorized from my provider and filled at Pharmacy. I am not able to request a cancellation once the prescription has been processed by the Pharmacy.
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