GLP-1 Weight Loss Follow Up Form
Please complete the questions below. This form is intended for established weight loss patients of BeneVita Aesthetics & Wellness only. If you are a new patient, please schedule a Medically Managed Weight Loss Consult through our booking portal prior to requesting treatment or medication. The information provided in this form is for clinical review purposes only and does not constitute medical advice, diagnosis, or treatment. Submission of this form does not guarantee a prescription, refill, or change in treatment. All requests are subject to provider review, medical appropriateness, and compliance with applicable Texas laws and regulations. By submitting this form, you certify that the information provided is accurate and complete to the best of your knowledge and understand that incomplete or inaccurate information may delay or affect your care.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Allergies
*
Shipping preference
*
Ship to me
Ship to BeneVita - I will schedule a med pick up
Pick up from pharmacy
Current Weight
*
Progress Since Last Visit?
*
Gained
Lost
Plateaued
Maintaining
Current Medication
*
Semaglutide/B12 (Hill Country Specialty Pharmacy/pink medicine)
Tirzepatide/B12 (Hill Country Specialty Pharmacy/pink medicine)
Carnisema (Lake Hills Pharmacy/clear medicine)
Carnitide (Lake Hills Pharmacy/clear medicine)
Current Dosing Schedule (please specify units and frequency)
*
Date of last injection?
-
Month
-
Day
Year
Date
Are you experiencing any side effects?
*
nausea
vomiting
reflux/heartburn
constipation
diarrhea
fatigue
hair loss
none
Other
Do you feel any dose adjustments are needed?
*
Yes, I would like to increase my dose
Yes, I would like to decrease my dose
no
Preferred pharmacy?
Hill Country Specialty Pharmacy (pink medicine)
Lake Hills Pharmacy (clear medicine)
No preference
If you are a current BeneBank member would you like for us to apply our wallet credits to your order if applicable?
*
Yes, use my credit
No, I'll save it for later
n/a
Do you need to discuss anything with a provider?
*
Yes
No
Notes to provider
Submit
Should be Empty: