This form is only for Existing Patients already enrolled in the GLP-1 Weight Loss Program, if you are a new patient please submit an appointment request by visiting us online at www.envogueivtherapyandwellness.com or by calling (215) 770-9780.

Once this form is properly submitted, you will be prompted with a message which states "Thank you! Your submission has been received". For any assistance with filling out or submitting this form, please feel free to contact us directly at (215) 770-9780 during our standard hours of operation.

By signing below i confirm that all the information I have provided is true and accurate to the best of my knowledge.

This Agreement is essential to the trust and confidence necessary in a prescriber/patient relationship. My prescriber has discussed my treatment plan with me. I understand that there is a risk of psychological and/or physical dependence and addiction associated with the chronic use of substances, whether controlled or not, for weight-loss. I have been told about the side effects that I may experience. My prescriber is undertaking to treat me with medications, which may include controlled substances, for weight loss or other conditions.

I {name}, understand and voluntarily agree to the following (Intial each statement after reviewing):

I have told my prescriber about other medications I am taking and my medical history, including my prior experience with weight-loss medications or other drugs. Throughout my treatment, I will communicate fully with my prescriber about the character and intensity of my weight, the effect of the weight on my daily life, and how well the medication is helping to assist with wieght-loss.

I will take my medication, as instructed and not change the way I take it without first talking to my prescriber or other members of the treatment team. I understand that my prescriber may change this medication during my course of treatment.

I will not attempt to obtain weight-loss medications from any other prescribers and understand that my precriptions will be issued only during scheduled office visits with the treatment team. I understand that my prescriber may change this medication during my course of treatment.

I agree not to use illegal drugs or alcohol while on these medications.

I understand that i should not drive a motor vehicle or operate machinery if the medication causes dizziness, drowsiness, or sedation.

I understand that I may be referred to other health care professionals for other modes of treatment, such as physical therapy, exercise, relaxation techniques or psychological counseling or for certain diagnostic tests and that my prescriber may speak with other health professionals about my treatment plan.

I will keep the medicine safe, secure, and out of reach of others, and will dispose of unused medication in a Project Medicine Drop Box, through a Take-back Program or in a drug disposal pouch.

I will not sell this medicine or share it with others. if my medicine or prescriptions is lost or stolen, I understand that it may not be replaced.

I understand that I may need to submit to random urine drug testing and pill counts if requested by my prescriber and that my prescriber will be verifying that I am receiving controlled substances from only one prescriber and only one pharmacy by checking the Prescription Monitoring Program web site.

I understand that if I do not follow all the terms of this Agreement, my prescriber may stop prescribing weight-loss medications, and/or that I could be required to find another prescriber or heatlh care professoinal for my future medical treatment.

I will keep all of my scheduled appointments for refills. If I am having trouble making an appointment, I will tell a member of the treatment team immediately. 

I understand that it is my responsibility to contact and notify En Vogue IV Therapy and Wellness that I am due for a refill 7-10 business days prior to my last dose. I understand that refill requests are submitted using this form and not by phone. I will not call outside of office hours, or at night or on the weekends looking for refills. I understand that prescriptions will be available for pick-up with the treatment team during regular office hours. Additionally, I am aware that if I do not pick up my medication and it expires, no refund will be provided, and there will be a fee to order a replacement.

**Please provide your email below for confirmation that your form has been submitted: