RETURNING PATIENTS | Lipsbymatt

Medical Questionnaire for Returning Patient

Please fill out the following form

First Name

Date of Birth

Last Name

Phone

Have you been hospitalized OR Have you had any changes in your health status since last consultation, such as new diagnosis of high blood pressure, thyroid or cardiac issues or others??

Yes

Have experienced any side-effects from the medications since last consulation?

Yes

Since last consultation, was your blood pressure:

NORMAL ( under 139/89)

ELEVATED ( Over 140/90)

EXTREMELY HIGH ( over 180/100)

UNSURE, but I do not have any new symptoms since last consultation

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete, Agreed to term & condition of telemedecineView terms of use

Thanks for submitting!

Once submitted you will receive a phone call consultation during business hours the same or following day with a medical provider to evaluate and decide if you are healthy enough to continue with the weight loss program.

If you want to set up a specific time, you can book it under "TELEMEDICINE" at a specific time and date during business hours, or text us a time.

Telemedecine has additional costs as listed below:

> remote payment credit card procession fee ...............$3.00

> Shipping and handling fee ..........................................$7.50

Total: $10.50 of additional fees

Payment will be processed over the phone right after your telemedecine consultation if you are a good candidate to continue with the weight loss program.