Weight-Loss Intake Form (7-day Free Trial) - Healthcare Intermediaries LLC

Weight-Loss Intake Form - Healthcare Intermediaries LLC
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Patient Gender *
Address
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone Number *

Area Code Phone Number
Patient E-Mail *
Reason for seeing the doctor: *

Weight-Loss Consultation
Patient Medical History and Preferences
Do you have a preferences as to which weight-loss medication you want? *

Ozempic Wegovy Rybelsus Mounjaro Saxenda Victoza Xenical No preference/let my prescriber decide
Do you have a history of any type of eating disorder (Bulimia, anorexia, binge eating disorder, etc.)? *

Yes No
If so, please elaborate: *
Select all that apply *

I am pregnant I am breastfeeding I am trying to get pregnant None of the following apply
Have you ever tried any weight loss medications in the past? *

Yes No
Which medication shave you tried in the past? Did it/they work? Why or why not? *
Past medical history: *

Cancer Cardiovascular: Heart condition/heart arrhythmia, heart attack, high blood pressure, hyperlipidemia/high cholesterol Endocrine: Diabetes, hypothyroidism, hyperthyroidism Gastrointestinal: Crohn’s disease, pancreatitis, liver disease, irritable bowel syndrome, ulcerative colitis, delayed gastric emptying Neurological: Stroke, seizures Psychological: Anxiety, depression, eating disorder Renal: Kidney disease Respiratory issues: Asthma, COPD, recurrent pneumonia Other/not listed
What type of Cancer?
Please list any other comments about your medical history:
Have you or anyone in your family ever been diagnosed Medullary thyroid cancer or any type of thyroid cancer? *

Yes, I have Yes, someone in my family has. No
Have you or anyone in your family ever been diagnosed with Multiple endocrine neoplasia type 2? *

Yes, I have Yes, someone in my family has. No
Please list any Operations *
Please list your Current Medications (prescribed, over the counter, vitamins, minerals, supplements, etc; Include Dosage, and Frequency)
Please list any drug allergies *
Please input your height and weight below to calculate your BMI:
Healthy & Unhealthy Habits
Exercise *

Never 1-2 days 3-4 days 5+ days
Eating following a diet *

I have a loose diet I have a strict diet I don't have a diet plan
Alcohol Consumption *

I don't drink 1-2 glasses/day 3-4 glasses/day 5+ glasses/day
Caffeine Consumption *

I don't use caffeine 1-2 cups/day 3-4 cups/day 5+ cups/day
Do you smoke? *

No 0-1 pack/day 1-2 packs/day 2+ packs/day
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

Area Code Phone Number
Pharmacy Fax (if known)

Area Code Phone Number
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. *

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/ *

I agree
I have read and agree to the Consent to Telehealth Agreement. They can be found at https://getsuboxone.com/consent-to-telehealth/ *

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. *

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

My Products

Weight-Loss Consultation $ 49.00

A doctor or nurse practitioner will review your questionnaire and prescribe a 30-day supply of a weight-loss medication if appropriate. If you have any questions about your treatment, you can send him or her a message and they'll respond within 24 business hours. A brief phone or video visit may be required based on state regulation. We will send you any necessary information before your visit.If the Provider determines you are not a good fit for weight-loss medication or you are not prescribed weight-loss medication, you will receive a full refund.

Total $ 0.00

Credit Card
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Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
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Weight-Loss Intake Form - Healthcare Intermediaries LLC

Patient Medical History and Preferences

Healthy & Unhealthy Habits

Pharmacy Information

Disclaimers