LeanerRx

LeanerRX

First name

Last name

Phone

Date of Birth

Have you had any side effects with the medication you received from LeanerRx?

Yes No

Please list all side effects.

Were these side effects tolerated?

Yes No

How was your appetite ?

How much weight you the lost during last month?

Have you started any new medications during the last month?

Yes No

If there is a message you want to send to your doctor please write below.

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