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Lips By M

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Medical Questionnaire

Please fill out the following form before the visit

First Name

Email Address

Phone Number

Last Name

Date of Birth * required

Zip Code

Address

Have you unexplained elevated blood pressure within the last 12 months? *

No

Yes

Past Medical History: Check all that apply. * Required

NONE

Thyroid disease

Hypertension

Heart condition (heart failure, arrhythmia, hx of heart attack...)

Elevated Cholesterol

Diabeter Mellitus

Liver disease

Kidney disease

Neurological conditions ( stroke, seizures disorder...)

Depression, Anxiety or other psychiatric disorder

Currenlty Pregnant ( WOMEN ONLY)

Currently Breastfeeding ( WOMEN ONLY)

Other medical conditions

I declare that the info I’ve provided is accurate & complete

Thanks for submitting part 1, now on to part 2!

Medical Questionnaire Part 2

Do you have any known medical allergies? *

No

Yes

Medications

Surgical History:

Family History

Diet & Exercise History:

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

I accept terms & conditions HIPAAView terms of use

I accept terms & conditions and consent to the weight loss program View consent form

Thanks for submitting!

If unable to fill above questionnaire online, CLICK HERE FOR PAPER VERSION: NEW PATIENT FORMS to bring at first visit

© 2024 by LipsByMatt . The contents of the Lipsbymatt website, such as text, graphics, images, and other material contained on the lipsbymatt website (“Content”) are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking treatment because of something you have read on the lipsbymatt website or affiliated sites. CONTENT AND PRICING SUBJECT TO CHANGE AT ANYTIME WITHOUT NOTICE

*Prescription products require an online evaluation with an independent licensed medical professional who will determine if a prescription is appropriate. See important safetyinformation. Benefits outlined on this website are based on 3rd party studies. Medications are prescribed by independent licensed physicians as part of our weight loss programs. Actual product packaging may appear differently than shown. Physicians may prescribe compounded medications as needed to meet patient requirements or drug shortages. The FDA does not review or approve any compounded medications for safety or effectiveness

The Provider will assess your suitability for the prescription item. If deemed suitable, a doctor may issue a prescription for the item, which can be filled at a partner pharmacy, unless you specify an alternative preference.

You also consent to us using your information for third-party advertising purposes, including but not limited to targeted advertising on platforms such as Facebook, Google, and other similar sites. This includes using hashed and de-identified data to create custom audiences for targeted advertising and to exclude existing customers from certain marketing campaigns. You can opt-out of receiving marketing emails at any time by following the unsubscribe instructions provided in each email or by contacting us directly at lipsbymat@gmail.com.

Note: The above statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.

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