Step 1 of 3 33% Patient InformationName(Required) First Last Email(Required) Phone(Required)Medication name(Required) Semaglutide (Injection) Semaglutide (Oral Tablets) Tirzepatide Lipo-B (one dose) Current dose?(Required)How long have you been on this dose?(Required)Date of last injection?(Required) MM slash DD slash YYYY Current weight?(Required)Overall ToleranceHow are you tolerating your GLP-1 or Lipo B medication overall?(Required) Very Well Well Fair Poor Have you missed any doses? If yes, please explain.(Required) Medication Side Effects (Past 7 Days)Please select the severity that best appliesNausea None Mild Moderate Severe Vomiting None Mild Moderate Severe Diarrhea None Mild Moderate Severe Constipation None Mild Moderate Severe Abdominal pain/cramping None Mild Moderate Severe Bloating or early fullness None Mild Moderate Severe Heartburn or refl ux None Mild Moderate Severe Injection Site Reactions None Mild Moderate Severe Appetite, Nutrition & HydrationChange in appetite:(Required) Significantly decreased Moderately decreased Slightly decreased No change Are you able to meet your daily protein and hydration goals?(Required) Yes, consistently Sometimes No Other Symptoms (check any that apply)You can select more than once choice Fatigue Dizziness/lightheadedness Headache Mood changes Hair loss I agree to notify my provider if I develop any of these RED FLAG symptoms: persistent vomiting lasting more than 24 hours, signs of dehydration such as dark urine, minimal urination, or dizziness, severe or worsening abdominal pain, symptoms of low blood sugar, or new right upper abdominal pain or gallbladder-type pain.(Required) I agreeDo you feel you are making progress toward your goals?(Required) Yes No Somewhat What is your goal weight?(Required)Any concerns or questions for your provider?(Required) Refill and Dose RequestDose Preference (Provider approval required)(Required) Decrease my dose Keep my dose the same Increase my dose Date you would like your order placed?(Required) MM slash DD slash YYYY Patient Acknowledgment: I confirm that the information above is accurate to the best of my knowledge. I understand that dose changes and refill approval depend on my symptom review and provider assessment. By selecting I agree, I authorize Flammingo Wellness to take payment from the card on file for the refill on the date listed above.(Required) I agreehCaptcha(Required)
