Stand Alone MIF - Phentermine - Medical Weight Loss Centers of America

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)

First Last

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Gender(Required)

Date of Birth(Required)

What is your current height?(Required)

What is your current weight?(Required)

What is your waist circumference? (Optional)

What is your body fat percentage? (Optional)

What is your resting heart rate? (BPM)(Required)

What is your current blood pressure reading that was taken in the last 7 days?(Required)

Have you completed a Physical Exam by a physician?(Required)

Yes

Are you currently taking any of the following medications?

MAOI's

Insulin

Oral anti-diabetic medications

SSRI's

adrenaline neuron blocking medications

dexfenfluramine

fenfluramine

None of the above

Do any of the following cardiovascular risk factors apply to you?

Hypertension

Hypercholesterolemia

DMII

Mother with heart attack or heart disease at 65yo or younger

father with heart attack or heart disease at 55yo or younger.

None of the above

Have you been diagnosed with any of the following?

What daily medications do you take?

What are your blood sugar levels?

When was your last A1c?

What was your last A1c?

What daily medications do you take?

Do you use recreational drugs?

Are you currently pregnant or are you trying to become pregnant?(Required)

Yes

Are you currently breastfeeding?(Required)

Yes

Do you have a family history of any of the following:

Anemia

Alzheimers

Heart Disease

Lipid Disorder

Stroke

Thyroid disorder

None of the above

Do you experience Chest pain or shortness of breath when climbing a couple of flights of stairs or walking several blocks?(Required)

Yes

Do you experience chest pain or shortness of breath with sexual activity?(Required)

Yes

Do you experience unexplained dizziness or fainting?(Required)

Yes

Do you experience prolonged cramping in the legs with exercise?(Required)

Yes

Do you experience abnormal heartbeats or rhythms?(Required)

Yes

How old were you when you began to have issues with your weight?(Required)

What has contributed to your issues with weight?

Unhealthy diet

Medications

Low levels of physical activity

Stressful life events

Depression

Injury

Illness

Other

Describe what other factors you think may have caused you to have issues with your weight?

Have you ever been diagnosed with an eating disorder?(Required)

Yes

Have you ever taken any prescription anti-obesity medication in the past?

Are you currently awaiting bariatric surgery?(Required)

Yes

Have you tried any weight loss method in the past?

Low-calorie diet

Specialized diet

Commercial weightloss plan

Weight loss supplements

OTC products

Exercise

Past surgeries

Other

None

For each weight loss method you've tried, how effective was it in helping you manage your weight?

Not effective

Mildly effective

Effective

Very effective

How would you describe your current diet?(Required)

Very healthy

Somewhat healthy

Somewhat unhealthy

Very unhealthy

Do you currently follow any of these diets?

Do you have any food intolerances?

How often do you eat fast food per week?(Required)

How often do you eat processed foods per week?(Required)

How often do you drink sugar-sweetened beverages per week?(Required)

How much does your weight negatively affect your health?(Required)

Quite a bit

A little bit

Not too much

Not at all

How much daily dietary fiber do you intake?(Required)

How much daily water consumption in ounces do you intake?(Required)

How do you rate your physical health?(Required)

Who does the grocery shopping for your household?(Required)

Who does the cooking in your home?(Required)

Is there anything specific that motivated you to make this change?(Required)

How would you describe the benefits of making a change?(Required)

How many days per week do you do at least 20 minutes of weight lifting or some form of strength training?(Required)

How many days per week do you get at least 30 minutes of moderate-intensity aerobic exercise?(Required)

Does your weight interfere with your ability to perform daily activities like running errands or family responsibilities?(Required)

Yes

On a scale of 1-10, how strong are the factors that could derail your change?(Required)

On a scale of 1-10, how confident are you in your ability to make the change?(Required)

Have you had any surgeries? Pleast list.(Required)

Please list any medication and supplements you are currently taking:(Required)

Please list any allergies you may have, including allergies to medication(Required)

Please review the agreement forms below and confirm your agreement by selecting the appropriate checkbox. Click here to view all policies and agreements.

I agree to the HIPAA Privacy Policy.

I agree to the Informed Consent for Telemedicine Services

I agree to the Patient Policy Agreement.

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.

I agreed to the informed consent for Phentermine.

Consultation Fee Consent(Required)

I acknowledge that the consultation fee is non refundable. By checking this box, you will not dispute the consultation fee if you do not qualify for the Phentermine program. If you do not qualify due to health risks, you are paying for the review of your medical history by a licensed medical professional. Even if you are disqualified for a certain program, the consultation fee can be applied to other programs on the website. Contact us for more information.

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