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TELEMED SCHEDULING FORM

In order to receive your purchases, you must fill out the Personal Information Form below and submit it to BiocoreHealthRX. We will assess and document the form and schedule a Telemed Appt with a Physician within 24 hours. After approval from the physician, your purchases will be released for shipping to you.
Enrollment Form
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Personal Information

Name
Birthday
Gender
Address
Is it all right to call you at the number listed:
Choose best number to reach you.

Spouse/Significant Other or Next of Kin

Name

Medical History

Are you aware of any medical reasons for weight gain?
Is your weight now stable?
Are you continuing to gain weight?
Are you taking any kind of medications, herbal therapies, non-prescription drugs, etc.?
Do you have allergies to any medications?
Any history of the following: Heart Diseases, Cardiovascular disease (heart or blood vessel), Stroke?
Clear Signature

Any history of the following (continued)

Pulmonary disease (lung) or asthma?
Diabetes?
Hypoglycemia?
Thyroid, Adrenal or PCOS problems?
Migraines or Seizures?
GI, Liver, Gallbladder problems?
Kidney or bladder problems?
Hypertension/ High blood pressure?
Orthopedic problems or surgeries?
Have you ever had problems with extreme nervousness, anxiety or panic attacks?
Have you ever had any weight loss surgery (liposuction, gastric banding / stapling, intestinal bypass, etc.)?
Other surgeries?
Have you ever taken, or are currently taking any of the following medications?(check all that apply)
Do you take Ritalin, Adderall, or any other stimulant therapies?
Do you take any of these MAOI’s? Isocarboxazid (Mar plan) / Phenelzine (Nardil) / Selegiline (Emsam) / Tranylcypromine (Parnate)
Daily Caffeine Intake?
Clear Signature

INTERNAL USE BELOW THIS POINT - DO NOT FILL OUT

Diagnosis: Overweight / Obese / Morbidly Obese / Localized Adiposity / Cosmetic Weight Loss Labs: CBC, CMP, Lipid, TSH, T4 Side Effects Explained
Plan: B12 / MIC
Also approved for B6 / B12 / MIC
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