Form | **APPROVED MASTER**

SSC Ticket Submission

The minimum necessary standard imposed under HIPAA requires covered entities to share the minimum necessary information with their business associates. Please include in this form the minimum necessary information for us to help answer your questions. Information such as name, date of birth, address of your patients or clients is not necessary and should not be included.

Clinic Name*

Email*

Are you a new Clinic?

Yes
No

Are you a new Coach?

Yes
No

Subject

Issue

Start Weight (in pounds)

Current Weight (in pounds)

Height (in feet e.g. 5'9)

Age

Sex

Male
Female

Number of Weeks on Protocol

Regular or Alternative Protocol

Regular
Alternative

Number of Packets Per Day

Please enter a number from 0 to 15.

Medication(s) and Dosage

Medications

Medication	Dosage

Click the + symbol to add additional medications.

Attachment

Drop files here or

Max. file size: 4 MB.