Patient Information

Full Name *

Date of birth *

Phone *

Email *

Current Medication Information

Current weight loss medication you are taking *

Current dose *

Date of your last dose taken *

Treatment Response

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

Additional Medications

Would you like a refill of your anti-nausea medication (Zofran)?

Yes

Dose Adjustment

How would you like to proceed with your next dose? *

Remain at the same dose

Increase dose

Decrease dose

Unsure – please contact me

Follow-Up Communication

Would you like our office to contact you with any questions or concerns before processing your refill? *

Yes

Refill Confirmation & Payment

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 at the processed by the Pharmacy.