Patient First Name *

Patient Last Name *

Date of Birth *

Used to match this follow-up to the correct patient chart.

Phone Number *

Email Address *

Who Completed This Form? *

Preferred Contact Method *

Text Message Opt-In *

Yes, I agree to receive text messages

You may receive appointment, refill, and follow-up text messages from MP Weight Loss. Message and data rates may apply. Reply STOP to opt out.

Progress & Measurements

Current Weight (lbs) *

Weight at Last Visit (lbs)

Goal Weight (lbs)

Date of Last Injection *

Current Dose

What is your current goal?

Side Effects & Safety Check

Are you experiencing any side effects? *

Yes

If yes, please describe your side effects

Have you had any nausea? *

Yes

Have you had any vomiting? *

Yes

Have you had any diarrhea? *

Yes

Have you had any constipation? *

Yes

Any other medications started since last visit?

Please report to the office if you experience any abdominal pain, and inform your PCP that you are using this medication.

Refills, Dose Concerns & Treatment Plan

Do you need a refill? *

Yes

Would you like a dose adjustment? *

No, stay the same

Yes, I'd like to increase

Yes, I'd like to decrease

Any additional concerns or questions for the provider?

Appointment Preference

Follow Up Appointment Form

GLP-1 Enhanced Follow-Up Form