Weight Loss New Patient Consent Form

Patient Basic Information Form:

to be filled out by the patient
Full Name*

First NameMiddle InitialLast Name
Gender*
Birth Date*

MonthDayYear
Date
Age*
Phone Number*
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient Basic Information

to be filled out by the patient
Preferred Pharmacy*
Pharmacy Phone Number*
Please enter a valid phone number.
Pharmacy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact*
First and Last Name
Emergency Contact Phone Number*
Please enter a valid phone number.
How did you hear about Better Beauty & Wellness, LLC?*
Referral's Name (they will get $20 off their next service!)*
First and Last Name
Other*

Financial Policy

Thank you for selecting Better Beauty and Wellness, LLC for your health care. We are honored to be of service to you and your family. This is to inform you of your billing requirements and our financial policy. Please be advised that payment for all services will be due at the time services are rendered. For your convenience we accept Visa, Mastercard, Discover, American Express, Venmo, HSA/FSA cards, and CareCredit.
I have read and understand all of the above and agree to the financial policy:*

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Date*

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Date
HIPAA Privacy Notice

I understand that Better Beauty & Wellness, LLC follows The HIPAA Privacy Rule which requires appropriate safeguards to protect the privacy of protected health information and sets limits and conditions on the uses and disclosures that may be made of such information without your authorization. The Rule also gives you rights over your protected health information, including rights to examine and obtain a copy of your health records, request corrections, or request it be sent to another party.
I have read and understand the HIPAA Privacy Notice*

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Date*

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Date

Informed Consent for Weight Loss
I,   First Name   Last Name (patient), understand and acknowledge that treatment by Better Beauty and Wellness, LLC, Dr. Melissa Pearce, MD and their designated providers is limited solely to assistance with weight reduction efforts. This treatment does not provide a substitute or replacement for any regular physician. Better Beauty and Wellness, LLC and Dr. Melissa Pearce, MD do not treat acute or chronic medical problems, and I agree to see my physician regularly.

I,   First Name   Last Name (patient), authorize Dr. Melissa Pearce, MD and whomever she designates as her providers to assist me in my weight reduction efforts. I understand my treatment may involve but is not limited to the use of appetite suppressants or GLP-1 injections for more than 12 weeks. I understand my program will consist of a balanced diet, a regular exercise program, and instructions in behavior modification techniques.

I have read and understand my doctor’s statements that follow:
“Medications, including the appetite suppressants, have labeling worked out between the makers of the medication and the Food and Drug Administration. This labeling contains, among other things, suggestions for using the medication. The appetite suppressant labeling suggestions are generally based on shorter term studies (up to 12 weeks) using the dosages indicated in the labeling.”
“As a provider, I have found the appetite suppressants are helpful for periods far in excess of 12 weeks and, when indicated, in increased doses. However, you must decide if you are willing to accept the risks of side effects, even if they might be serious, for the possible help the appetite suppressants use in this manner may give.”

I understand it is my responsibility to follow the instructions carefully, and to report any significant medical problems that I think may be related to my weight control program to the doctor or nurse practitioner treating me for my weight as soon as reasonably possible.

I understand the purpose of this treatment is to assist me in my desire to decrease my body weight and maintain this weight loss. I understand that continuing to receive weight loss interventions will be dependent on my progress in weight reduction and weight maintenance.

I understand there are other ways and programs that can assist me in my desire to decrease my body weight and to maintain this weight loss.

Risks of Proposed Treatment (appetite suppressants): I understand this authorization is given with the knowledge that the use of the appetite suppressants, including for more than twelve weeks involves some risks and hazards. The more common side-effects include: nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, psychological problems, medication allergies, high blood pressure, rapid heartbeat, and heart irregularities. Less common, but more serious, risks are primary pulmonary hypertension and valvular heart disease. These and other possible risks could, on occasion, be serious or fatal. I understand that if I have questions or concerns about the side effects or risks, to seek the provider available at Better Beauty and Wellness, LLC.
Risks of Proposed Treatment (Semaglutide/GLP-1): I understand this authorization is given with the knowledge that a glucagon-like peptide-1 receptor agonist is prescribed as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) that is considered outside a healthy range. Do not take this medication if you have a family history of thyroid cancer or Multiple Endocrine Neoplasia Syndrome Type 2, history of pancreatitis, you are pregnant or plan to become pregnant while taking this medicine. You are diabetic and/or taking any medications related to lowering your blood sugar levels without speaking with your endocrinologist, if you are prescribed Insulin because the combination may increase your risk of hypoglycemia (low blood sugar) and dosage adjustments by your provider may be necessary, you are allergic to BPC-157, Semaglutide or any other GLP-1 agonist such as: Adlyxin®, Byeta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy®, or if you have other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details. Before using this medication, tell your doctor/pharmacist your medical history. Common side effects of Semaglutide include nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dyspepsia, dizziness, abdominal distension, belching, hypoglycemia, flatulence, gastroenteritis, and gastroesophageal reflux disease. Subcutaneous Injections: common injection site reactions characterized by itching, burning at site of administration with or without thickening of the skin(welting). If you notice other side effects not listed above, contact your doctor or pharmacist.

No Guarantee: I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I also understand that I will have to continue watching my weight all my life if I am to be successful in maintaining the weight loss achieved.
Patient’s Consent: I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained, or any questions I have concerning them have not been answered to my complete satisfaction. I have been urged to take all the time I need in reading and understanding this form and talking with my doctor regarding risks associated with the proposed treatment and other treatments not involving the appetite suppressants or GLP-1 drugs. I also understand that participation in this program is strictly voluntary and it is my choice to participate or not. I understand that I may discontinue this treatment at any time at my discretion.
Warning: If you have any questions as to the risks or hazards of the proposed treatment, or any questions whatsoever concerning the proposed treatment or other possible treatments, ask your provider now before signing the consent signature form.
Shipments: I understand that neither Better Beauty & Wellness, LLC nor the provider are responsible for medications during shipment. If medication is not delivered correctly, but has the correct address on the label, the patient is responsible for replacement of the medication.

I have read and fully understand this consent form. I realize I should not sign this form if all items have not been explained to me.
My questions have been answered to my complete satisfaction. I have been urged and given all the time I need to read and understand this form.
Signature*

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Date*

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Family History
Do you have a parent or sibling who has had a Heart Attack, Stent, Bypass Surgery, or Angina?*

YesNo
Were they UNDER the age of 55?*

YesNo
My mother/father/sister/brother* had heart condition* . They were age* years old when it happened.
Add another?

YesNo
My mother/father/sister/brother* had heart condition* . They were age* years old when it happened.
Would you like to write more?
This is a complete and full disclosure of my medical history.*

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Date

MonthDayYear
Date

Lifestyle Evaluation
What is the main reason for your decision to lose weight?
What is your desired weight?
What do you think caused your weight gain?
What diets have you followed in the past and did you have good results?
Do you drink caffeinated drinks?
How much per day?
Do you drink alcohol?
How many drinks do you consume per day or per week?
Do you smoke?
Do you exercise regularly?
How many times per week?
What forms of exercise do you enjoy?

Consent to Treatment (Women Only)
I understand that phentermine and other anorectic medications should not be taken during pregnancy, due to the chance of adverse effects to the baby. The medications have been explained to me fully and I am aware of the risks involved.

To the best of my knowledge, I am not pregnant. I am aware of the precautions that should be taken to avoid pregnancy while on the medications. If I become pregnant, I will advise both Better Beauty and Wellness, LLC and my OB/GYN immediately.
Signature*

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Date*

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Disclosure and Consent Form
To the Patient: You have the right, as a patient, to be informed about your condition and how integrative and alternative medicine may be applied in a treatment plan. This disclosure is intended to provide an opportunity for you to make an informed decision so that you may give or withhold your consent to treatment that may be considered unconventional. Notice: Refusal to consent to the integrative and alternative treatment(s) shall not affect your right to future care of treatment.

I voluntarily request that Dr. Melissa Pearce, MD and other affiliated health care providers may treat my condition as described below:

I understand that some of, or all of, the following integrative and alternative treatments are planned for me, and I voluntarily consent and authorize the following: Administration of homeopathic remedies, herbal and nutritional therapies, off label use of pharmaceuticals, injectable vitamins and Amino Acids, B12 with or without lipotropic, Choline, Methionine, Inositiol as well as:

I understand that no warranty or guarantee has been made regarding results of treatment. I realize that there may be risks and hazards related to the planned integrative treatment, including worsening of present symptoms, development of new symptoms (especially detox reactions) and undesirable interactions between various treatments, both conventional and alternative, as well as:

I have been given an opportunity to ask questions about the treatment of this health condition using conventional, integrative, and alternative methods. I have had an opportunity to discuss the possible risks and hazards of treatment and non-treatment, and I believe that I have sufficient information to this informed consent. I certify this form has been fully explained to me, that I have read it (or have had it read to me), that the blank spaces have been filled in, and that I understand its contents. I also certify that the Provider at Better Beauty and Wellness, LLC has provided this Disclosure and Consent Form to me and fully explained the diagnostic and treatment options available and has made no guarantees to me as to the success of this treatment. I acknowledge that the provider at Better Beauty and Wellness, LLC has informed me that he functions only as an educator and consultant not as the primary care provider for any patient. I have assured him that I have another primary provider and do not/ will not rely on providers at Better Beauty and Wellness, LLC for that role.
Signature*

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Date*

MonthDayYear
Date

Can't wait to see you!

If you have questions, you can contact me using the information below -- otherwise go on and hit submit!
Should be Empty:

	Name of Medication	Prescription or Over-the-Counter?	Dosage	Schedule
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6

	Check if NO	Check if YES	Give more detail if desired.
High Blood Pressure
Diabetes
Seizures
ADHD or Narcolepsy
Heart Attack, Angina, Stents, or Chest Pain
Heart Valve Disorder
Heart Disease
Anemia
Bleeding Disorder
Thyroid Problems Including Thyroid Cancer
Cancer
Pancreatitis
Kidney Disease
Liver Disease
Glaucoma
Gallbladder Disorder or Removal
Constipation
Mental Health/Psychiatric Diagnoses
Addiction to Alcohol or Other Drugs
Use of Illicit Drugs
Eating Disorder
Other

Patient Basic Information Form:

Patient Basic Information

Informed Consent for Weight Loss

Medical Information & History

Family History

Lifestyle Evaluation

Consent to Treatment (Women Only)

Disclosure and Consent Form

Can't wait to see you!