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Medical History Form
PhentermineRx.online
32
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HIPAA
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1
Are you a Returning Patient?
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2
Full Name
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First Name
Last Name
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Hi, {FullName:first} Happy You're Here! What state do you live in?
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Alabama
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Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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4
{FullName:first}, what is your telephone number?
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Please enter a valid phone number.
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{FullName:first} what is your age?
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{FullName:first} what is your date of birth?
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Date
Month
Day
Year
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7
{FullName:first}, what is your gender?
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Male
Female
N/A
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Male
Female
N/A
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8
{FullName:first} what is your email address?
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example@example.com
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9
{FullName:first}, what is your weight today?
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10
{FullName:first}, what is your goal weight?
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11
What is your height?
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12
{FullName:first} Please check the conditions that apply to you
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No health conditions or diagnosis
Asthma
Cancer
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Thyroid Cancer
Chest pain
Respiratory
Hematological
Lymphatic
Neurological
Psychiatric
Musculoskeletal
Gall bladder Disease
Crohn's Disease
Ulcerative Colitis
IBS
Pancreatitis
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13
Phentermine is in short supply in many pharmacies nation-wide. Some pharmacies may be unwilling to dispense phentermine. Thankfully, there are other strong FDA-approved appetite suppressants. These are very effective weight loss medications too : like Contrave® (naltrexone / bupropion) . {FullName:first} would you prefer any of these medications if Phentermine is not an option for you?
Please Select
Yes, I am open to other appetite suppressants, and or other physcian prescribed weight loss medications
My preference is Phentermine
Please Select
Please Select
Yes, I am open to other appetite suppressants, and or other physcian prescribed weight loss medications
My preference is Phentermine
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14
Have you taken any appetite suppressants in the past?
YES
NO
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15
I voluntarily consent to any and all health care treatment and diagnostic procedures provided by this clinic and its associated physicians, clinicians and other personnel. I am aware that the practice of medicine and other health care professions is not an exact science and I further state that I understand that no guarantee has been or can be made as to the results of the treatments or examinations at this clinic. {FullName:first} please SIGN HERE.
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16
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. {FullName:first} Do you have any of these health conditions or are you on any of these medications?
YES
NO
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17
Due to some local pharmacies making decisions to delegitimize patient's needs for Phentermine treatment via telehealth, a few patients may experience delays receiving their prescriptions or some local pharmacies 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 {FullName:first} sign here
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18
{FullName:first} are you currently taking any medication?
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19
Please list them.
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20
Do you have any medication allergies?
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Yes
No
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21
Please list them.
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22
{FullName:first}, do you use any kind of tobacco or have you ever used them?
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Yes
No
Please Select
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Yes
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23
What kind of tobacco products? How long have you used/been using them?
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24
Do you use any kind of illegal drugs or have you ever used them?
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No
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25
What kind of drugs? How long have you used/been using them?
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26
{FullName:first}, how often do you consume alcohol?
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Daily
Weekly
Monthly
Occasionally
Never
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27
I agree to be contacted via email or SMS with information related to my visit, like: a patient portal invitation, post-visit satisfaction survey, appointment or checkup reminders, health tips, or new services that relate to me or my family. I authorize non-refundable payment of medical benefits to this LifeLabb Health and Wellness GLP1Rx.online or their designee for services rendered. I give permission to obtain all my medication/prescription history when using an electronic system to process prescriptions for my medical treatment. I voluntarily consent to any and all health care treatment and diagnostic procedures provided by LifeLabb Health and Wellness Glp1Rx.online and its associated physicians, clinicians and other personnel. I am aware that the practice of medicine and other health care professions is not an exact science and I further state that I understand that no guarantee has been or can be made as to the results of the treatments or examinations at this clinic. {FullName:first} please SIGN HERE
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28
When you pay for an appointment we automatically reserve a spot for you immediately on the doctor's/practitioner's calendar. That means all purchases are final. Once paid, all fees are non-refundable regardless of whether services are utilized or not. Should you be unable to attend your scheduled appointment, please inform us by texting 702-900-5433 (LIFE) 24/hrs in advance and we will gladly arrange a new appointment at a time that suits you better, or alternatively, provide you with a clinic credit. Should there be a payment dispute, you agree to contact dispute@glp1rx.online prior to taking any further action or requesting additional services. please sign our no-refund policy below. {FullName:first}, please SIGN HERE
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29
{FullName:first} the law requires proof that physicians and or practitioner's prescribe Phentermine and any other weight loss medications only for legitimate medical purposes. Please Upload your FULL BODY picture here
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30
{FullName:first}, please Take a Photo. Our platform is HIPPA compliant, and no one will have access to your photos or information you provided other than your clinical practitioner and or physician.
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31
{FullName:first}, please upload your Driver's License
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32
MEDICATION PREPARATION AND DELIVERY AGREEMENT : Once you submit your order, our compounding pharmacy will begin preparing your medication. This process typically takes 5-7 business days, sometimes longer depending on availability. As soon as your medication is ready, it will be shipped directly from the pharmacy to you overnight to your provided address. {FullName:first}, please sign below to agree to this disclosure.
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33
You will receive email notifications regarding the status of your appointment, including confirmation when your provider has dispatched your prescription to the pharmacy. Additionally, we will send you a reminder for your subsequent follow-up appointment to your correct email address and you agree to opt-in to our email communication?
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34
{FullName:first}, please schedule telemedicine appointment.
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35
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ORDER SUMMARY
Total cost
USD
Phentermine
30 day supply
$
99.00
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36
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