Patient Follow-Up & Update Please complete verification first. Step 1 of 2 50% Please confirm that the information listed above is accurate.(Required) Correct Needs Updating Which information needs updating? Please select all.(Required) Phone Email Address Pharmacy Phone(Required)Email(Required) Enter Email Confirm Email Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Pharmacy Name(Required)Pharmacy Phone(Required) Breakfast / Meal 1(Required)Snack / Meal 2Lunch / Meal 3(Required)Snack / Meal 4Dinner / Meal 5(Required)Snack / Meal 6Have you experienced any side effects? Check below and/or describe below.(Required) No / None Headache Nausea Constipation Palpitations Dizziness Diarrhea Visual Disturbance Shortness of Breath Other (describe below) Have you experienced any side effects?(Required)Additional Notes to Share?
