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English (US)
Healthcare Intermediaries - Free 7-Day Naltrexone Trial Form
Patient Name
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First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Patient Gender
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Please Select
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
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-
Area Code
Phone Number
Patient Height (in's)
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Patient Weight (lbs)
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Patient E-Mail
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Reason for seeing the doctor:
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Alcoholism / Naltrexone Consultation
Patient Medical History
Please list any drug allergies
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Have you ever had (Please check all that apply)
Anemia
Asthma
Arthritis
Cancer
Gout
Diabetes
Emotional Disorder
Epilepsy Seizures
Fainting Spells
Gallstones
Heart Disease
Heart Attack
Rheumatic Fever
High Blood Pressure
Digestive Problems
Ulcerative Colitis
Ulcer Disease
Hepatitis
Kidney Disease
Liver Disease
Sleep Apnea
Use a C-PAP machine
Thyroid Problems
Tuberculosis
Venereal Disease
Neurological Disorders
Bleeding Disorders
Lung Disease
Emphysema
Other illnesses:
Please list any Operations
Please list your Current Medications (Include Dosage, and Frequency)
Do you take any opioids (legal or illegal)? These include prescription medications such as Vicodin, OxyContin, and Percocet. They also include street drugs like heroin and fentanyl. It is very important you do not take Naltrexone with opioids as it can cause Precipitated Withdrawal.
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IT IS VERY IMPORTANT PATIENTS DO NOT TAKE NALTREXONE AND AN OPIOIDS CONCURRENTLY. TAKING BOTH MEDICATIONS CAN CAUSE OPIOID WITHDRAWAL. BY SELECTING THE BUTTON BELOW, I AGREE I DO NOT CURRENTLY TAKE ANY OPIOIDS, LEGAL OR ILLEGAL, AND AGREE NOT TO DURING MY TREATMENT. I FURTHER AGREE TO NOTIFY ALL MY FUTURE PROVIDERS OF MY TREATMENT WITH NALTREXONE. I ALSO AGREE I
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I HAVE READ AND FULLY ACCEPT THESE TERMS
Healthy & Unhealthy Habits
Exercise
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Never
1-2 days
3-4 days
5+ days
Eating following a diet
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I have a loose diet
I have a strict diet
I don't have a diet plan
Alcohol Consumption
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I don't drink
1-2 glasses/day
3-4 glasses/day
5+ glasses/day
Caffeine Consumption
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I don't use caffeine
1-2 cups/day
3-4 cups/day
5+ cups/day
Do you smoke?
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No
0-1 pack/day
1-2 packs/day
2+ packs/day
Include other comments regarding your Medical History
Pharmacy Information
Which pharmacy should we send your prescriptions to?
Pharmacy Name
*
Pharmacy Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pharmacy Phone Number
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Area Code
Phone Number
Pharmacy Fax (if known)
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Area Code
Phone Number
Alcohol Assessment (AUDIT)
How often do you have a drink containing alcohol?
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Never [Skip to Qs 9-10]
Monthly or less
2 to 4 times a month
2 to 3 times a week
4 or more times a week
How many drinks containing alcohol do you have on a typical day when you are drinking?
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1 or 2
3 or 4
5 or 6
7, 8, or 9
10 or more
How often do you have six or more drinks on one occasion?
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Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often during the last year have you found that you were not able to stop drinking once you had started?
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Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often during the last year have you failed to do what was normally expected from you because of drinking?
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Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
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Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often during the last year have you had a feeling of guilt or remorse after drinking?
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Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
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Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Have you or someone else been injured as a result of your drinking?
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No
Yes, but not in the last year
Yes, during the last year
Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down?
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No
Yes, but not in the last year
Yes, during the last year
Please give us any more information about your alcohol use that you think may be useful. Please indicate whether you've used Naltrexone before.
What is the best time to contact you? Please add (800) 771-8770 as a contact so you know when one of our Providers is calling.
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Disclaimers
By clicking "I agree," I agree and understand the following terms. I understand Healthcare Intermediaries, LLC is an intermediary between practitioners and patients; Healthcare Intermediaries, LLC assists in connecting practitioners to patients to provide medical services. I agree to hold Healthcare Intermediaries, LLC harmless from and against any and all claims, damages, costs and expenses, including attorneys' fees, arising from or related to your use of our Company or any Contracts or Services you purchase through it. This release include any and all actions or inactions taken by any affiliated Healthcare Practitioners.
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I agree
I have read and agree to the full Terms and Conditions of Healthcare Intermediaries, LLC. They can be found at https://getsuboxone.com/terms-and-conditions/
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I agree
I have read and agree to the Consent to Telehealth Agreement. They can be found at https://getsuboxone.com/consent-to-telehealth/
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I agree
You are currently set to receive text messages for appointment reminders and information about your health care treatment. If you wish to decline receiving all text messages from Healthcare Intermediaries LLC click here.
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I agree to receiving text messages about my care. SMS allows you to receive faster care by providing an easy way to get in-touch with you . You may opt-out anytime by texting "STOP" to 800-771-8770.
OPT-OUT
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