(B) Juno Reorder Form

Welcome to JUNO

At The Weighting Room
Patient MEDICATION Re-Order Form

(Must be completed in full before any medication is approved)
Your Contact Details:
Full Name*

First NameLast Name
Address*

House Name/Number

Street/Road Name

TownState / Province

Post Code
Phone Number*
E-mail*
Personal Details:
Height:*
Starting Weight:*
Current Weight:*
Waist Measurement:*
Chest Measurement:*
Hips Measurement:*
Arms Measurement:*
Thighs Measurement:*
Are you currently taking any new medications or have a confirmed medical condition/illness?*
How are you feeling overall since your last order?*
Are you experiencing ANY side effects? please list all *
Nausea, Constipation, Diarrhoea, Reflux/burps, Headache, Injection site issues
Are you experiencing any POSiTIVE changes*
Control of Appetite, More Energetic, Self confidence, better Sleeping etc
On a scale of 1 to 10, how do you feel emotionally about taking your medication *
1 = Negative, 10 = postive
Are you eating a minimum of 50g of protein daily*
Yes or No
Are you drinking at least 3 litres of water daily *
Yes or No
Which Medication and dose are you reordering *
4 weeks supply
I confirm that all information I have provided regarding my Medical history, current medications, allergies and intolerances, and any other relevant health conditions is complete, accurate and upto date to the best of my knowledge. i understand that this information is essential for my safety and to ensure the appropraite diet plan is provided.

I acknowledge that the clinic and its practitioners cannot be held responsible for any adverse effects, complications, or outcomes that may arise as a result of inaccurate, incomplete or withheld information.

I accept full responsibility to ensure the clinic is kept fully update in the future.

GLP-1 Clients

I understand and agree that Juno Transformtive Weight Loss clinic except no liablity or responsibility for any individual taking a GLP-1 medication with the clinic. The responsibility and Liability for the use of such medication lies solely with the individual client
Signature*

Clear
Date:
Should be Empty:

Welcome to JUNO

Patient MEDICATION Re-Order Form

Your Contact Details:

Personal Details: