Weight Loss Program Check-In

En Vogue IV Therapy & Wellness
Weight Loss Program Check-In
This form is for existing patients currently enrolled in a provider-directed weight loss program. If you are a new patient, please submit an appointment request by visiting www.envogueivtherapyandwellness.com or by calling (215) 770-9780.

Information submitted through this check-in will be reviewed by your provider. All treatment decisions, including medication and dosing, are determined by your provider.

Instructions:

► Please click the Patient Check-In section below to begin and complete all required fields.

► Important - The provider section is for internal use only and should not be completed.

► Once this form is completed, please scroll to the bottom and click the Submit button.

► You will then see a confirmation message stating “Thank you! Your submission has been received.”

If you need assistance completing this form, please contact us at (215) 770-9780 during our standard hours of operation.
Medical provider:
- Weight-Loss Program Check-In
- Is this check-in for a routine follow-up and refill review?
- Program Type (as assigned by provider)
- Current Weekly Dose (mg)
  ⚠️ Enter your dose in mg (milligrams), NOT units or mL. ► You can find your prescribed dose in mg on your medication label or packaging. Example: 0.25 mg, 0.5 mg, 1.0 mg
- Date of last dose taken
  
  MonthDayYear
  Enter the date of your most recent dose (injection or oral). If you missed a dose, enter the last date you took or administered your medication.
- How long have you been in the program
- Are you taking your medication regularly as prescribed by your provider?
- Please explain why you are not taking your medication as directed by your provider.
- Are you currently experiencing any side effects from your medication?
- Please provide any additional details on any side-effects you may be experiencing.
- Have there been any changes to the medications you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements?
- Please provide any additional details on any changes to your medication including prescription and over-the-counter medicines, vitamins, and herbal supplements. Please include dosing and frequency.
- Current Weight (lbs)
  Please enter your current weight in pounds.
- Have there been any changes in your weight since your last check-in?
- Please provide additional details on any changes or progress since starting your weight loss program.
- Are you maintaining a healthy diet?
- Please provide additional details about your diet.
- Are you incorporating physical activity/exercise into your lifestyle?
- Please provide additional details about your physical activity/exercise regimen.
- Confirm Mailing Address (Please make sure information is accurate)
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Program Acknowledgment & Financial Responsibility
- By submitting this form, I confirm that I am actively participating in the program and wish to continue treatment. I understand that all program fees, services, and associated costs are non-refundable, and I am fully responsible for all program-related payments regardless of usage or outcome.
  
  I acknowledge that all treatment decisions, including medication and dosing, are determined at the sole discretion of my provider. I understand that medications, when prescribed, are fulfilled by a licensed pharmacy. I agree to take all medications exactly as directed and to follow all instructions provided. I understand that results may vary.
  
  I confirm that the information provided in this check-in is accurate to the best of my knowledge. I understand that failure to provide accurate information, follow instructions, or communicate concerns may impact my treatment and results. I agree to communicate any side effects, concerns, or changes in my condition to my provider.
  
  I understand the importance of not using additional weight loss medications or similar treatments from other sources without informing my provider. I agree to disclose any medications or treatments I am using so that my provider can make safe and appropriate decisions regarding my care.
  
  ► I understand that this form must be submitted at least 5 business days prior to my last scheduled dose to allow adequate time for review and processing. Late submissions may result in delays in treatment.
  
  I agree not to share, sell, or misuse any medication prescribed to me and understand that I am responsible for storing medication safely and keeping it out of reach of others.
  
  I understand that my provider may modify or discontinue treatment at any time based on clinical judgment.
  
  By signing below, I confirm that all information provided is true and accurate to the best of my knowledge, and I acknowledge and agree to the terms outlined above.
- Patient Name
  
  First NameLast Name
- Patient Signature
- Date Signed & Submitted by Patient:
  
  MonthDayYear
  Date
- Patient Date of Birth:
  
  MonthDayYear
  Date
- **Please provide your email below for confirmation that your form has been submitted:
- Patient Email (optional — for submission confirmation)
  example@example.com
- Provider Review (Internal Use Only)
  
  Completed by the provider after reviewing the patient’s submission. This section documents the provider’s decision regarding continuation or adjustment of the treatment plan.
- Provider Decision
- Prescribed Dose (mg)
  Enter the prescribed weekly dose in mg (milligrams).
- Prescribed Dose Frequency
- Reason for Decision
  
  Other
- Include Additional Clinical Notes? (Optional)
- Additional Notes:
  Enter any additional clinical notes or relevant updates, if applicable.
- Provider Signature
- Prescription Status (Internal Use Only)
- Notes (Internal Use Only)
Reply Email
Should be Empty:

En Vogue IV Therapy & Wellness

Weight Loss Program Check-In

Weight-Loss Program Check-In

Program Acknowledgment & Financial Responsibility

Provider Review (Internal Use Only)