Huntsville Emotional Wellness Center

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for and/or (Outpatient

Patient Name *

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Last

Phone Number

Email Address *

Reason for Appointment (Outpatient Suboxone and Weight Loss Clinic) *

• Outpatient Suboxone treatment (medication-assisted treatment for opioid use disorder)
• Weight loss clinic evaluation and management
• Both outpatient Suboxone and weight loss clinic services
• Follow‑up visit for existing outpatient Suboxone or weight loss clinic care

Brief Medical History (Suboxone treatment and/or weight loss goals)

Additional Questions or Comments for Outpatient Suboxone and Weight Loss Clinic

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