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Home/Stand Alone MIF – Phentermine
Stand Alone MIF – PhentermineMedical Weight Loss Centers of America2022-04-14T14:23:25+00:00

Important: Please fill in the below form. Please make sure the information you provide below matches the information on your order. This information is to verify your current details and is required for prescription purposes via telemedicine. All information provided below is encrypted and secure. Once we have received your physical examination form and medical release form, you will be contacted to schedule a video conference with one of our prescribing physicians.
Name(Required)
Address(Required)
Have you completed a Physical Exam by a physician?(Required)
Are you currently taking any of the following medications?
Do any of the following cardiovascular risk factors apply to you?
Have you been diagnosed with any of the following?
Do you use recreational drugs?
Are you currently pregnant or are you trying to become pregnant?(Required)
Are you currently breastfeeding?(Required)
Do you have a family history of any of the following:
Do you experience Chest pain or shortness of breath when climbing a couple of flights of stairs or walking several blocks?(Required)
Do you experience chest pain or shortness of breath with sexual activity?(Required)
Do you experience unexplained dizziness or fainting?(Required)
Do you experience prolonged cramping in the legs with exercise?(Required)
Do you experience abnormal heartbeats or rhythms?(Required)
What has contributed to your issues with weight?
Have you ever been diagnosed with an eating disorder?(Required)
Have you ever taken any prescription anti-obesity medication in the past?
Are you currently awaiting bariatric surgery?(Required)
Have you tried any weight loss method in the past?
For each weight loss method you've tried, how effective was it in helping you manage your weight?
How would you describe your current diet?(Required)
Do you currently follow any of these diets?
Do you have any food intolerances?
How much does your weight negatively affect your health?(Required)
How do you rate your physical health?(Required)
Does your weight interfere with your ability to perform daily activities like running errands or family responsibilities?(Required)
Terms of Use, HIPAA Privacy Policy, and Agreement Forms(Required)
Please review the agreement forms below and confirm your agreement by selecting the appropriate checkbox. Click here to view all policies and agreements.
Phentermine Informed Consent(Required)
I authorize Medical Weight Loss Centers of America, LLC and whomever this entity designates as its medical providers to assist me in my weight reduction efforts.

I understand my treatment may involve, but is not to be limited to, the use of: appetite suppressants for more than 12 week when indicated, balanced diet, regular exercise, and instructions on behavior modification techniques.

I have read and understand my doctor’s statement that is listed below. “Medications, including the appetite suppressants, have labeling worked out between the makers of the medication and the Food and Drug Administration. This labeling contains among other things, suggestions for using this medication. The appetite suppressant labeling suggestions are generally based on shorter term studies (up to 12 weeks) using the dosages indicated in the labeling.”

I understand it is my responsibility to follow the instructions carefully and to report to the health care provider (Physician/NP/PA) treating me for my weight, any significant medical problems and medical history, and change in medications, as soon as reasonably possible. I understand my continuing to receive the appetite suppressant will be dependent on my progress in weight reduction and weight maintenance.

I understand this authorization is given with the knowledge that the use of appetite suppressants for more than 12 weeks and in higher doses than the doses indicated in the labeling involves some risks and hazards. The more common include: nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, psychological problems, medication allergies, high blood pressure, rapid heart beat, and heart irregularities. Less common, but more serious risks are primary pulmonary hypertension and heart disease. These and other possible risks could, on occasion, be serious or fatal.

I understand I need to stop taking the appetite suppressant if swelling, shortness of breath, heart arrhythmia, increasing blood pressure or heart fluttering develops and notify the health care provider.

I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful.

I understand I cannot obtain appetite suppressants elsewhere while taking the medication from this clinic.

I understand this is a prescription medication and it is illegal to share with anyone else. I cannot receive medication early for any reason including lost or stolen pills.

I understand I cannot get refills on medication without meeting with the health care provider unless the following criteria are met; It has been over 21 days since the last refill, bloodwork is less than 90 days old, there are no new medications or side effects, there has been weight loss.

I understand there are no refunds or returns.
Consultation Fee Consent(Required)
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