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Injectables Weight Loss Medication Follow-up

Prior to ordering your refill for the injectable weight loss medication, Dr. Clark requires you to complete this short assessment. Please take a few moments to answer these questions...

You will receive an email with the link to complete your purchase following submission.

Click the button below to start.

Start

Question 1 of 8

What is your current weight?

Question 2 of 8

Are you having any side effects?

A

Yes

B

No

Question 3 of 8

If yes, what side effects are you experiencing?

(Select all that apply)
A

Nausea

B

Vomiting

C

Diarrhea

D

Constipation

E

Other

F

N/A

Question 4 of 8

Do you want to continue?

A

Yes

B

No

Question 5 of 8

Do you want to increase your dose?

A

Yes

B

No

Question 6 of 8

Would you like to be contacted by the office?

A

Yes

B

No

Question 7 of 8

What questions or concerns may we address?

Question 8 of 8

You acknowledge that the purchase of this medication is non-refundable. To complete your purchase, please select the order link on the next screen. 

Thank you.

 

A

Yes

Confirm and Submit