Follow up Weight loss intake

FOLLOW UP WEIGHT LOSS (for returning patients only)

This form is for patients currently under our care for weight loss management.
In order to ensure a good and productive in-person or telemedicine/telephone visit, Dr Urick wants to ensure we have the most up to date information on you.

THIS FORM IS HIPAA SECURE! We will receive it securely once you submit it.
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Patient E-Mail*
example@example.com
Todays Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Concerning refills for my medication:*

I am ready to increase my dose on this refill - please process the refill (Note: We will send an email or text once the order has been placed and a receipt emailed to you from your chart)I am not sure if I am ready to increase my dose / I would like to discuss this.I am at the maximum dose and would like to refill at this dose - please process the refill (Note: We will send an email or text once the order has been placed and a receipt emailed to you from your chart)
Which medication and dose are you currently taking?*
What is your most recent weight/ current height?*
Are you experiencing any side effects from this medication? (symptoms may include nausea, heart burn/reflux, vomiting, diarrhea, lightheadedness, constipation, etc)
Have any of your prescription medications or medical diagnoses/history changed since our last visit/telemedicine visit with you?*
If yes, what has changed
Is there anything in particular that you would you like to discuss during your telemed call/office visit (if you elect to have a telemed call or appointment)?
Medication refill
If you elected above to speak with us about your dose, When is a good day(s)/time(s) for us to call you? (PLEASE NOTE: We are closed on Saturday/Sunday. Please see hours on the Weight Loss Section of our website.)
Once you have your initial in-person visit to get started on injectable GLP-1 medications, we will want you to be seen in the office within 3-4 months.

For refills of compounded medication we do prefer that you be seen in person at least every 3-4 months (or at minimum once a year)

We can reach out to you once we receive this form if we are making a change in your dose to confirm your information above. We will need to place the order for the compounded medication to be shipped to your address listed. Payment is required before the order can be placed. Once the product has shipped and been received it can neither be returned nor a refund issued.
DateTime
Credit/Debit/HSA Card Authorization
Patient Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Patient E-Mail*
example@example.com
DateTime
For the compounded medication that will be ordered for me today by Dr Urick, I authorize Urick Internal Medicine to charge my card on file for the cost of the medication. I understand that once my credit/debit/HSA card is charged that I will receive an email receipt from Urick Internal Medicine. I understand that in order for my medication to be ordered I will need to pre-pay.
Signature*

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FOLLOW UP WEIGHT LOSS (for returning patients only)

Medication refill

Credit/Debit/HSA Card Authorization