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Email:
Info@IVLinfusions.com
Phone:
561-489-7100
Fax:
561-680-3630
Request an Appointment
Phone:
561-489-7100
Fax:
561-680-3630
Email:
Info@IVLinfusions.com
Home
For Patients
What Makes Us Different
How To Get Started
Patient Faq
Therapies
Wellness
Our Team
Leadership
Forms
Physician
Contact Us
Request an Appointment
Menu
Weight Loss Prescription Form
First Name
*
Last Name
*
Date of Birth
*
Social Security
*
Gender
*
Male
Female
Address
*
City
*
State
*
ZIP
*
Home Phone
Cell Phone
*
Medication (SEMAGLUTIDE)
Orders
PLEASE CHECK ONE
WEEK 1 – 4 (0.25 MG SC WEEKLY)
WEEK 5 – 8 (0.5 MG SC WEEKLY)
WEEK 9 – 12 (1.0 MG SC WEEKLY)
WEEK 13 – 16 (1.7 MG SC WEEKLY)
WEEK 17+ ( 2.4 MG SC WEEKLY (MAINTENANCE)
ADD ON
ZOFRAN 8 MG ODT Q 8-12 HRS PRN For Nausea
LABS
*
CMP/12
CBC
Hemoglobin A1C
TSH,T3,T4
Lipids
Vitamin D
Current Patient Weight
*
Height
*
Initial Patient BMI
*
Current Patient BMI
*
Does the patient have a comorbid condition?
*
Dyslipidemia
Hypertension
Type 2 Diabetes
Other
Start date of weight management medication
*
Document lifestyle modification, (if applicable)
*
Caloric Restriction
Exercise
Other
MD Signature
*
Date
*
MD Name
*
NPI
*
DEA
*
Phone
*
Fax
Contact
*
Address
*
City
*
State
*
ZIP
*
Submit
Please do not fill in this field.
