Size8Clinic Weight Loss Intake Form

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Invoice ID
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Full Name* This field is required.
First Name
Last Name
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More Details* This field is required.
Date Of Birth
Gender
Please Select
Please Select
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Minor Outlying Islands
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
U.S. Virgin Islands
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Please Select
Please Select
Single
Married
Divorced
Other
Marital Status
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Contact Details* This field is required.By entering your phone number you are giving us consent to contact you via SMS or Phone calls to schedule appointments
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Email
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Phone
Email
Preferred Contact Method
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Pharmacy Preferences* This field is required.What would you do if your pharmacy doesn't have Phentermine in stock or won't dispense Phentermine, ? Note: This clinic is a clinic. Not a pharmacy. So we neither sell nor dispense any medication .We are not affiliated with any pharmacy. We don't guarantee that any pharmacy will dispense phentermine (whether they have it or not). After your appointment your medical provider will send your script electronically to your pharmacy. If phentermine is not in stock at your pharmacy your medical provider can switch it to another weight loss medication available or you can wait until its available at your pharmacy
I will wait for my pharmacy to get the medicationI will try another appetitie supressant
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Phentermine* This field is required.Phentermine is in short supply in many pharmacies nation-wide. Some pharmacies may be unwilling to dispense phentermine due to the Biden administration new regulation. Thankfully, there are other strong FDA-approved appetite suppressants. These are very effective weight loss medications too, like Contrave® (naltrexone / bupropion) . We can give you a coupon too to save you money. Would you prefer any of these medications? *Generic contrave is almost the same price as Phentermine
Yes, Contrave worksNo, I want phentermine
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Coupon* This field is required.Would you like for us to send you coupons for Brand-name Contrave and Diethylpropion?
YESNO
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Medication Allergies* This field is required.Are you allergic to any medications. if Yes list the medications. if no write "None"
YESNO
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Medication Allergy List* This field is required.
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Small
Ok
Ok
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Current Medication* This field is required.Are you on any current medication?
YESNO
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Current Medication List* This field is required.
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Small
Ok
Ok
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BMI Factors* This field is required.
Height
Weight
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Contrave Drug Interraction* This field is required.Do not take CONTRAVE if you have uncontrolled high blood pressure, have or have had seizures, use other medicines that contain bupropion such as WELLBUTRIN, WELLBUTRIN SR, WELLBUTRIN XL, APLENZIN and ZYBAN, have or have had an eating disorder called anorexia or bulimia, are dependent on opioid pain medicines or use medicines to help stop taking opioids, or are in opiate withdrawal, drink a lot of alcohol and abruptly stop drinking, or use medicines called sedatives (these make you sleepy), benzodiazepines, or anti‐seizure medicines and stop using them all of a sudden; are taking or have taken medicines called monoamine oxidase inhibitors (MAOIs) in the past 14 days; or are allergic to any of the ingredients in CONTRAVE. Do you have any of these health conditions or are you on any of these medications?
YESNO
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Contrave Side Effects* This field is required.Stop taking CONTRAVE and call a healthcare provider right away if you or your family members notice any of the following symptoms, especially if they are new, worse, or worry you: thoughts about suicide or dying; attempts to commit suicide; depression; anxiety; feeling agitated or restless; panic attacks; irritability; aggression, anger, or violence; acting on dangerous impulses; an extreme increase in activity and talking; other unusual changes in behavior or mood; trouble sleeping. Is that ok?
YESNO
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Contrave Contraindications* This field is required.Contrave should not be taken with certain medications like Digoxin, haloperidol, risperidone and thioridazine Are you on any of these medications?
YESNO
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Phentermine Contraindications* This field is required.ADHD stimulants and phentermine cannot be taken at the same time. We will prescribe an alternative for you to lose weight if you are on stimulants. Are you on Adderall or other stimulant medications?
YESNO
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Phentermine and Seniors* This field is required.Phentermine is not recommended for patients over the age of 65 because it can cause some health problems. So if you are above 65 our provider will prescribe an alternative medication for you. Is this okay?
YESNO
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Success Factors* This field is required.Appetitie supresants works best in combination with a healthy diet and exercise regimen. Have you taken any appetite suppressants in the past?
YESNO
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Pharmacy State* This field is required.Select your state and see whether you can pick up your medication in the local pharmacy or Mail order pharmacy?
Please Select
Please Select
Alabama - Mailorder
Alaska - Mailorder or Local pharmacy
Arizona - Mailorder or Local pharmacy
Arkansas - Mailorder
California - Mailorder or Local pharmacy
Colorado - Mailorder or Local pharmacy
Connecticut - Mailorder
Delaware - Mailorder or Local pharmacy
Florida - Mailorder or Local pharmacy
Georgia - Mailorder or Local pharmacy
Hawaii - Mailorder
Idaho - Mailorder or Local pharmacy
Illinois - Mailorder
Indiana - Mailorder
Iowa - Mailorder
Kansas - Mailorder
Kentucky - Mailorder
Louisiana - Mailorder
Maine - Mailorder
Maryland - Mailorder
Massachusetts - Mailorder
Michigan - Mailorder or Local pharmacy
Minnesota - Mailorder
Mississippi - Mailorder
Missouri - Mailorder
Montana - Mailorder
Nebraska - Mailorder
Nevada - Mailorder or Local pharmacy
New Hampshire - Mailorder
New Jersey - Mailorder or Local pharmacy
New Mexico - Mailorder or Local pharmacy
New York - Mailorder or Local pharmacy
North Carolina - Mailorder
North Dakota - Mailorder
Ohio - Mailorder or Local pharmacy
Oklahoma - Mailorder
Oregon - Mailorder or Local pharmacy
Pennsylvania - Mailorder
Rhode Island - Mailorder
South Carolina - Mailorder or Local pharmacy
South Dakota - Mailorder
Tennessee - Mailorder or Local pharmacy
Texas - Mailorder or Local pharmacy
Utah - Mailorder
Vermont - Mailorder
Virginia - Mailorder or Local pharmacy
Washington - Mailorder
West Virginia - Mailorder or Local pharmacy
Wisconsin - Mailorder
Wyoming - Mailorder
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Pharmacy Type* This field is required.Your medication can either be sent to your local pharmacy or mail order pharmacy and delivered to your home. Which would you prefer?
Local PhamacyMail Order Pharmacy
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Local Phamarcy DetailsWhat is the name of your pharmacy?
Pharmacy Name
Please Select
Please Select
Arizona
Washington
State
City
Zip Code
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Upload your drivers license* This field is required.
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Max. file size: 10.6MB
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Full Body Picture* This field is required.The law requires proof that doctors prescribe Phentermine only for legitimate medical purposes. Please upload your full body picture here.
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Max. file size: 10.6MB
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Contact Consent Signature* This field is required.By providing your phone number, you are giving us consent to contact you via SMS or phone call. You can always opt-out by texting the word stop to 1 (833) 747-4938. Sign below .
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Prescription Signature* This field is required.Due to some local phamacies making decisions to delegitmize patient's needs for Phentermine treatment via telehealth, a few patients may experience delays receiving their prescriptions or some local phamacies may outrightly refuse to fill telehealth scripts. In that case we will automatically send your script to a mail-order pharmacy and your meds will be delivered to you within 2-3 days. Sign below .
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Not-A-Pharmacy disclosure signature* This field is required.WE-ARE-NOT-A-PHARMACY DISCLOSURE: Size8clinic is a clinic and not a pharmacy. We won't sell any medication to you. You are only paying us for your doctor's appointment, not the cost of your medication. We are not affiliated with any pharmacy, so we have no way of knowing whether your pharmacy has phentermine in stock or not. We therefore don't guarantee that your pharmacy will stock/dispense phentermine. After your appointment, your medical provider will send your script, electronically, to your pharmacy. If phentermine is not in stock or the pharmacies won't dispense it, the medical provider can switch phentermine to a different weight loss medication in stock. Please sign below to agree to this disclosure.
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Refund Policy Signature* This field is required.REFUND POLICY When you pay for an appointment we automatically reserve a spot for you immediately in the doctor's calendar. That means all purchases are final. Once paid, all fees are non-refundable regardless of whether services are utilized or not. If you can't make your appointment, send a text to ‪(833) 747-4938‬, we can reschedule you to a more convenient date or we may issue you a clinic credit. That way you can use your clinic credit for any future appointment for weight loss or even primary care. If you mistakenly paid twice for one appointment we will be happy to refund the second payment. Should there be a payment dispute, you agree to contact care@size8clinic.com prior to taking any further action or requesting additional services. Please sign our no-refund policy below.
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