Refill Request- Med Spa of Kingwood

Oral Weight Loss Refill Request

Please allow 48-72 hours for approval. Blood Pressure must be updated with each refill request.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medication Allergies?*
Please list all medications you currently take*
Are you having any problems with the medication or side effects? please check all that apply*

NoneElevated Blood PressureElevated Heart RateSevere Constipation
Have you recently been diagnosed with one of the below?*

HyperthyroidismADHDPregnancyHeart Disease (palpitations, chest pain, CAD)GlaucomaAre you BreastfeedingHypertensionNONE
Do you have any questions or suggestions you would like to discuss with the Provider?
Current Weight (pounds)*
Please list pharmacy with address if needed *
Please upload a picture of your blood pressure and heart rate captured on an automatic blood pressure cuff*

This is a requirement*
Cancelof
Please Upload a copy of your Driver's License*

Cancelof
Financial Agreement

Payment is due in full at the office of the service. I agree to pay in full for all services if I choose to have the service provided.
Treatment Consent and Autorization

I consent to medical screening via telemdedicine to determine my health status. I acknowledge that the practice of medicince is not an exact science and that no guarantees have been made to me as to the outcomes of the visit.
HIPPA

The Med Spa of Kingwood upholds the standards of HIPPA laws. As a patient, we want you to know:

We respect the privacy of your personal medical records and will do all we can to secure and protect that privacy
When it is appropriate and necessary we provide the minimun information to only those in need of your personal information in order to provide healthcare that is in your best interest
You may refuse to consent to the use or disclosure of your health information but this must be in writing
Under this law we have the right to refuse to treat you should you refuse to disclose your personal health information

My Products

Medical Weight Loss Refill Request- 1 monthMedication is sent to the local pharmacy of your choice

$100.00

Total

$0.00

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Oral Weight Loss Refill Request

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