GLP-1 Weight Loss Follow Up Form
Please complete the questions below.
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)
Tirzepatide/B12 (Hill Country Specialty Pharmacy/pink)
Carnisema (Lake Hills Pharmacy/clear)
Carnitide (Lake Hills Pharmacy/clear)
Current Dosing Schedule (please specify units and frequency)
*
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)
Lake Hills Pharmacy (clear)
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: