Ontario · adult pre-visit intake

Weight management assessment.

A clear, structured questionnaire for professional review. It does not diagnose a condition, choose a medication, or guarantee treatment.

About 4–5 minutes

One section at a time.

Most answers are simple selections. You only type details when they are actually useful to the healthcare professional.

18+ onlyOntario focusedProfessional review required

Privacy & consent

Your answers are collected to coordinate and support professional review. Full health answers stay in the secure backend; notification emails contain only a reference number and care area. Read the privacy notice.

About youBasic information needed to coordinate care.

Full nameEmailPhone optionalAge range

Are you currently located in Ontario?

A regulated professional must confirm your identity and location before providing virtual care.

What you want reviewedTell the clinician what brings you here.

What would you like help with?How long has this been a concern?Have you discussed this concern with a healthcare professional before?

Medical historyOnly broad history is required here.

Do you have any ongoing medical conditions or significant past surgeries?Have you been admitted to hospital or visited an emergency department in the last 12 months?Do you have a regular family doctor, nurse practitioner, or other primary-care provider?Have you had routine bloodwork or health testing in the last 12 months?

Medicines & allergiesThese details help prevent avoidable medication problems during professional review.

Do you take any prescription medicines regularly?Do you have any medication allergies or previous serious medication reactions?

Final notes & consentReview these acknowledgements before submitting.

Anything else the healthcare professional should know? optionalI confirm I am 18 years of age or older and I am submitting this information for myself.I understand what information is being collected and why, and I consent to RefyllRx using it to coordinate and support professional review. I may choose not to submit this form.I understand that my identity must be confirmed before virtual care is provided.I understand that my current location must be confirmed before virtual care is provided.I understand this form is not monitored for emergencies and I should call 911 or seek urgent care for severe or rapidly worsening symptoms.

Submitting this form does not create a clinician-patient relationship and does not guarantee treatment or a prescription.