Beluga Portal

Ashley Bergner

Female · 9/25/1984 (40y) · WA menuDots

Phone: 3603199363

All Visits (2)

Weightlossfollowup

Master Id: 62fd0963-564b-4573-a567-a737420a1ddd

Active

Current Visit

Created on: 5-12-2025

Updated on: 5-12-2025

Weightloss

Master Id: ae795dc8-ef38-4dc1-90bc-7683e08a0138

Resolved

Go to this visit

Created on: 3-3-2025

Updated on: 3-5-2025

Resolved on: 3-5-2025 (Prescribed)

baskAmbleHealth Weightlossfollowup

Active Visit

Master Id: 62fd0963-564b-4573-a567-a737420a1ddd

Consents for telemedicine and privacy policy signed?	true
First Name	Ashley
Last Name	Bergner
Date of Birth	09/25/1984
Phone Number	3603199363
Email	1120297+1109125@bask.health
Address	1327 Grant Street
City	Bellingham
State	WA
Zip	98225
Sex	Female
Patient preference	Name: TxPromed Tirzepatide/B12 10mg strength: 10mg/ml refills: 0 quantity: 2 mL MedId: TXPRO-155196391-TB6
Self-reported Meds	None
Allergies	No
Medical Conditions	No
Weightloss Change	increase
Current Dose	Weightloss3
Current Weightloss Med	tirzepatide
Refill Consent ---------- Fulfillment I understand typical pharmacy fulfillment ranges from 7-10 business days, but may arrive sooner. ---------- Returns I understand if prescribed, this medication will be made specifically for me and such prescription medication is not eligible for return. ---------- Cancellations I understand that upon a script (eRX) being issued and sent to a partner pharmacy, my order cannot be changed. Amble will make every effort possible to cancel the order with the pharmacy but make no implied guarantee. In the event the order can be cancelled, a $100 nonrefundable visit and clinical fee will be withheld from your refund. ---------- Customer Information I understand that I am responsible for filling out this questionnaire accurately and my answers will be used by my medical provider in determining medical appropriate treatment. ---------- Order Processing I understand that proceeding and enrolling will constitute an order being processed. ---------- Treatment I acknowledge that there are risks of side effects or other outside medical events, such as potential pregnancy. However, these risks do not absolve financial responsibility for the medication, even if discontinuation is necessary before the treatment course is completed. There is no implied guarantee with medication and it is nonrefundable. ---------- Disclaimer Amble Health prescribes medications like Ozempic, Wegovy, or Zepbound, These are among the most effective weight loss medications on the market. Membership includes a provider consultation and prescription (if appropriate), access to GLP-1 medication, and the ongoing care and support you need to keep the weight off. † Ozempic®, WeGovy®, Saxenda®, and Victoza® are registered trademarks of Novo Nordisk. Zepbound® and Mounjaro® are registered trademarks of Eli Lilly. Amble Health is not affiliated with Novo Nordisk or Eli Lilly, and the compounded products offered by Amble are not produced by these companies. Compounded medications may be prescribed when appropriate based on patient medical need. While federal law allows the prescription of compounded drugs, they are not FDA-approved and do not undergo safety, effectiveness, or manufacturing review.	I understand that by continuing and acknowledging the aforementioned terms this will serve as my digital signature.
How are you doing on the current medication? Well Not well	Well
What is your current Height and Weight?	"Height: 5'8 Weight: 240lbs BMI: 36.49"
Have you had any side effects from the current medication? No Yes	No
Are you ready to increase your dose or stay at the same dose? Increase Stay at the same dose Stop the medication	Increase
Have there been any health changes, medication changes, ED visits or hospitalizations since your last check in? There have been no changes Inflammatory bowel disease Pancreatitis Pancreatic cancer Gallbladder disease Hypertriglyceridemia (elevated triglycerides) Kidney injury or kidney disease Insulin-dependent diabetes Thyroid cancer Family history of thyroid cancer Family history of MEN-2 syndrome PCOS with fertility problems Eating disorder, past or present Suicidal thoughts in the past 12 months Anorexia or bulemia Gastroparesis	There have been no changes
Do you take any of the following medications? Yes No	No
Are you currently pregnant or planning to become pregnant soon? Yes No	No
Are you currently breastfeeding? Yes No	No
Please review and agree to the following breastfeeding/pregnancy precaution ---------- Pregnancy and Breastfeeding precaution The FDA says that these medications may pose a risk to the developing fetus (baby) if you get pregnant while taking it “The pill” (oral contraception) is not enough because this medication can interfere with the effectiveness. For birth control you must use condoms, an IUD, or the implant. Official FDA recommendations: For the first month after first starting a weight loss medication, and for the first month after each dose escalation, continue using your oral contraception and add a barrier method of contraception (such as condoms) to prevent pregnancy. Alternatively, you can switch to a non-oral contraceptive method (such as an IUD or implant) before starting your medication. When you stop the medication, you must continue using a backup method (like condoms) for two months after stopping to allow the medication to fully leave your system before getting pregnant. Similarly, it is not known to be safe in breastfeeding. If you are breastfeeding, consult your doctor for safe weight loss options	By checking this box, you acknowledge the above information
Do you have anything else you want to let your doctor know? Yes No	No

Medicine Selection

Pharmacy:TXPM TX Performance Meds, Pharmacy

Search Medication

Deselect All

Zepbound 2.5mg

Zepbound 5mg

Zepbound 7.5mg

Zepbound 10mg

Zepbound 12.5mg

Zepbound 15mg

Assessment & Plan (Internal Note)

Patient has been educated on the treatment plan including instructions for use, risks/benefits/side effects.
No contraindications, red flags, or dangerous polypharmacy interactions identified.
If any side effects occur they should discontinue use and contact me for further instruction, except in the case of severe side effects in which case they should seek urgent care in an emergency room.
FOLLOW UP: The patient has been provided information on how to contact our medical team to follow up if any medical concerns or reactions to treatment arise at any time.
The patient is recommended to follow up with myself or the support team if additional concerns arise or the treatment plan needs to be adjusted.
Patient has been educated that there are limitations to telemedicine care, and in-person care may be necessary in certain situations (ER if severe side effects develop or through an in-person physician if signs/symptoms develop that warrant additional work up/evaluation/alternative treatments).
To the extent that I have been made aware by the company with which I contract to provide medical services,
the patient has signed relevant attestations prior to being assigned to me as a clinician that state that the patient is aware of any limitations in a virtual health encounter and understands that urgent or emergent care must be pursued in person.
I have confirmed the patient's identity via review of a legally recognized form of ID or through a second party identity verification service.
Please see doctor/patient messaging thread for any relevant dialogue which, in addition to providing supplemental medical information as needed, secures and meets the legally-defined doctor-patient relationship.
Telemedicine is appropriate for this patient encounter because it can meet the same standard of care for this patient's chief complaint and can improve access to care which remains limited in many parts of the United States.