Weight-Loss Intake Form - Healthcare Intermediaries LLC

Patient Name*

First NameLast Name

Date of Birth*

Date

Patient Gender*

Address

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number*

Area CodePhone Number

Patient E-Mail*

Reason for seeing the doctor:*

Weight-Loss Consultation

Do you have a preferences as to which weight-loss medication you want?*

If your insurance denies your preferred medication, would you be willing to receive a different medication instead? It's similar to Ozempic except it's $25 for a one-month or three-month supply.

Do you have a history of seizures? If so, please elabortate:

Are you on any psychiatric medication including anti-depressants?

What was your most recent blood pressure?

Please input your height and weight below to calculate your BMI:*

Do you have a history of any type of eating disorder (Bulimia, anorexia, binge eating disorder, etc.)?*

YesNo

If so, please elaborate:*

Select all that apply*

I am pregnantI am breastfeedingI am trying to get pregnantNone of the following apply

Have you ever tried any weight loss medications in the past?*

YesNo

Which medication shave you tried in the past? Did it/they work? Do you have an idea why or why not?*

Past medical history:*

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 haveYes, someone in my family has.No

Have you or anyone in your family ever been diagnosed with Multiple endocrine neoplasia type 2?*

Yes, I haveYes, 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*

Do you have health insurance?

YesNo

If you have your health information available, please upload an image of the front and back of your prescription health insurance card. Otherwise you can email it to insurance@healthcareintermediaries.com at a later time.

Browse Files

Exercise*

Never1-2 days3-4 days5+ days

Eating following a diet*

I have a loose dietI have a strict dietI don't have a diet plan

Alcohol Consumption*

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day

Caffeine Consumption*

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day

Do you smoke?*

No0-1 pack/day1-2 packs/day2+ packs/day

Pharmacy Name*

Pharmacy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Pharmacy Phone Number

Area CodePhone Number

Pharmacy Fax (if known)

Area CodePhone Number

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

Weight-Loss Services*

Monthly Weight-Loss Consultation($99.00 for each month)

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 medication, simply message through your provider and he/she will respond within 2 business days. 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 the weight-loss medication you originally selected, we will do our best to find a suitable alternative. However, we cannot guarantee you will receive a prescription. This is a monthly prescription and it will automatically renew on this day next month. Email us anytime at weightloss@healthcareintermediaries.com to cancel. Please note--this does not include the actual price of the medication. We cannot guarantee your insurance will cover it, but we will do whatever we can to help you get your medication, including completing prior authorizations and calling your insurance company.

3-Month Weight-Loss Subscription($249.00 for each three months)

Same terms and details apply from above except your you're purchasing a 3-month treatment subscription instead of 1 month. Please note--this does not include the actual price of the medication. We cannot guarantee your insurance will cover it, but we will do whatever we can to help you get your medication, including completing prior authorizations and calling your insurance company.

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Weight-Loss Intake Form - Healthcare Intermediaries LLC

Patient Medical History and Preferences

Insurance

Healthy & Unhealthy Habits

Pharmacy Information

Disclaimers