BSMD VIRTUAL NEW PATIENT PAPERWORK

Blue Sky MD Virtual Patient Registration Form
Patient/Child First Name*
MI
Last Name*
Age
Date of Birth

MonthDayYear
Date
Occupation
Ethnicity

HispanicNot HispanicUnknown
Language

EnglishSpanishOther
Race

WhiteBlackNative AmericanAsianOther
Marital Status

SingleMarriedWidow/WidowerDivorced
Social Security #
Mailing Address
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
Email address
example@example.com
Drivers License #
Primary Care Provider
Parent/Guardian (REQUIRED IF PATIENT IS UNDER 21 YEARS):

NOTE: Per NC Law, Both Parents can be held responsible for medical bills for minors, a medical practice is NOT bound by any separation agreement, divorce or child support order.
Parent/Guardian
Birth Date

MonthDayYear
Date
Address (if different from above)
Social Security # (required)
Employer
Preferred Phone #
In case of an emergency, who would you like to be contacted?
Contact Name
Relationship to Patient
Home Phone #
Work Phone #
By signing, you agree the information above is correct and give permission for Lamond Family Medicine and Blue Sky to file claims on your behalf.

HIPAA CONSENT: Without signed consent, we can NOT share information regarding your medical care (including family Please list anyone you would like to have this information below. (leave blank if you would not like any additional individuals to have information regarding your care.
1. Print Name*
Patient/Guardian Signature*

Clear
2. Print Name
Date

MonthDayYear
Date
Financial Policy and Signature on File

I authorize the release of any medical pertinent information to my consulting provider, if needed and as necessary to process insurance claims, insurance applications and prescriptions. I also authorize payment of benefits to both LaMond Family Medicine and Blue Sky MD.

I understand that the Virtual program subscription is fully self-pay and all subscription payments must be paid to remain in the program. In the event that I decide to receive care at the practice, the ability to file to my insurance for my care may be possible.

If filing insurance, I understand that I am financially responsible for all services rendered including for the following reasons:

1) No proper referral at the time of service or referral is invalid/expired

2) Incorrect/invalid insurance information given or failure to give new updated insurance information

3) Expenses not covered by insurance

4) Deductible not met

5) Services rendered are deemed medically unnecessary by insurance.

Failure of insurance company to pay does not excuse patient’s financial responsibility. It is patient’s responsibility to know what is and is not covered by their insurance policy/plan (including Medicare beneficiaries).

PLEASE READ CAREFULLY THE TERMS APPLICABLE TO YOUR SELECTED PAYMENT METHOD AND THE TERMS APPLICABLE TO ALL PAYMENTS METHODS (INCLUDED BELOW

Your consent to the terms of this Agreement confirms the following:

You authorize LaMond Family Medicine, PLLC dba Blue Sky MD (“Company”), to store the credit card identified with your purchase or payment information, as such credit card may be updated from time to time (the “Stored Credential” )

You give permission to the noted financial institution (or any substitute thereto which you identify) to charge the Stored Credential for withdrawals made by Company.

You understand the terms and conditions of your scheduled payment plan with Company and you authorize Company to make recurring charges to the Stored Credential for payment amounts you authorized or authorize from time-to-time and, if necessary, initiate adjustments for any transactions.

Without limiting the generality of the foregoing, you authorize Company to charge the Stored Credential in the amount of your total subscription, plus taxes if applicable, according to the payment frequency you select or selected. The current amount of your total current subscription, plus taxes if applicable, will be shown on your account statement.

You understand the amounts charged to the Stored Credential may vary if changes occur to your subscription.
Patient OR Guardian Signature for Financial and Office Policies: Refusal to sign does NOT prevent responsibility/obligation regarding this office’s financial policy*

Clear
HIPAA COMPLIANCE STATEMENT - THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

At this practice, we are committed to protecting your privacy. We comply with all federal, state, and local laws. This notice describes how we use your health information. It describes some of your rights and some of our responsibilities.

UNDERSTANDING YOUR HEALTH RECORD/INFORMATION - Each time you visit our offices, we record your symptoms, physical examination, test results, diagnosis, and treatment. This information enables us to plan for your care, communicate with others who care for you, report to your insurance carrier, bill for our work, and improve the quality of our care to you.

YOUR RIGHTS - Although your medical chart belongs to our practice, the information contained in the chart is yours. You have the right to inspect your records, obtain a copy of your chart for a small fee, correct your records, and tell us not to release your information to certain parties.

OUR RESPONSIBILITIES - We are required to maintain the privacy of your health information, send needed health information to other medical providers, and release information to insurance companies, certain government agencies, and others. We may be required to release some information, even without your permission.

EXAMPLES OF HOW YOUR INFORMATION IS USED - Your health information will be recorded and used to plan your treatment. Reports may be sent to other doctors to help them plan your treatment. Claims will be sent to your insurance company. The information in the claims will include confidential information such as your name, address, diagnosis, and treatment. In providing your care, we may communicate with other individuals or businesses. Examples include other physicians and/or laboratories. To protect your privacy, we ask our business associates to safeguard your information.

OTHER NOTICES - We may leave a message at your home, at your business, on your answering machine or on your voicemail. We may mail you a postcard or other written notices. We may need to disclose your information to your family members or other people helping with your care. In doing so, we will use our best judgment. We may disclose information to others as required by law or if subpoenaed. If you were injured on the job, we will need to disclose your health information to your workers compensation insurance company. We may, from time to time, update these policies.

FOR MORE INFORMATION, QUESTIONS OR TO REPORT A PROBLEM - If you have concerns or would like additional information, you may contact the Office Manager.
Signature: (HIPAA Policy)*

Clear
Date

MonthDayYear
Date
Health History

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

List your prescribed drugs, over the counter medications and supplements

	Name of Drug:	Strength:	Frequency Taken:
Drug 1
Drug 2
Drug 3
Drug 4

Personal Health History: List any medical problems that other doctors have diagnosed:

	Year:	Medical Problem:	Treatment/Medication(s): (if prescribed)
Problem
Problem
Problem
Problem

Allergies to Medications:

	Name of Drug/Medication:	Reaction
Drug 1
Drug 2
Drug 3

Surgeries:

	Year:	Type of Surgery:	Surgery Reason:
Surgery 1
Surgery 2
Surgery 3
Surgery 4

Hospitalizations:

	Year:	Reason:
Hospitalization 1
Hospitalization 2
Hospitalization 3

Weight Intake and History
Patient Height
Current Weight
Goal Weight
1. When did you begin gaining excess weight? (Give reasons, if known)
2. List previous diets you have followed (Give dates and results of weight loss):
3. Do you wake up hungry at night?

YesNo
4. List food allergies, if any.
5. List food dislikes, if any.
6. What foods do you crave?
7. Do you frequently skip meals?

YesNo
8. Have you ever been prescribed any of the following medications? (Mark all that apply)

PhentermineOzempicVictozaQsymiaOther
9. Do you have any of the following conditions? (Mark all that apply)

Medullary Thyroid DiseaseActive Pancreatitis
10. Do you have any of the following complaints/symptoms?

FatigueSleep IssuesHair LossJoint PainConstipationFoggy ThinkingTemperature SensitivityLow LibidoBrittle NailsDecline of Overall Well-Being
Eating Habits in the Past Year
1. I ate to the point where I felt physically ill.

NeverLess than once a monthOnce per month2-3 times per monthOnce per week2-3 times per week4-6 times per weekEvery day
2. I spent a lot of time feeling sluggish or tired from overeating.

NeverLess than once a monthOnce per month2-3 times per monthOnce per week2-3 times per week4-6 times per weekEvery day
3. I avoided work, school, or social activities because I was afraid I would overeat there.

NeverLess than once a monthOnce per month2-3 times per monthOnce per week2-3 times per week4-6 times per weekEvery day
4. If I had emotional problems because I hadn't eaten certain foods, I would eat those foods to feel better.

NeverLess than once a monthOnce per month2-3 times per monthOnce per week2-3 times per week4-6 times per weekEvery day
5. My eating behavior caused me a lot of distress.

NeverLess than once a monthOnce per month2-3 times per monthOnce per week2-3 times per week4-6 times per weekEvery day
6. I had significant problems in my life because of food and eating. These may have been problems with my daily routine, work, school, friends, family, or health.

NeverLess than once a monthOnce per month2-3 times per monthOnce per week2-3 times per week4-6 times per weekEvery day
7. My overeating got in the way of me taking care of my family or doing household chores.

NeverLess than once a monthOnce per month2-3 times per monthOnce per week2-3 times per week4-6 times per weekEvery day
8. I kept eating in the same way even though my eating caused emotional problems.

NeverLess than once a monthOnce per month2-3 times per monthOnce per week2-3 times per week4-6 times per weekEvery day
9. Eating the same amount of food did not give me as much enjoyment as it used to.

NeverLess than once a monthOnce per month2-3 times per monthOnce per week2-3 times per week4-6 times per weekEvery day
10. I had such strong urges to eat certain foods that I couldn't think of anything else.

NeverLess than once a monthOnce per month2-3 times per monthOnce per week2-3 times per week4-6 times per weekEvery day
11. I tried and failed to cut down on or stop eating certain foods.

NeverLess than once a monthOnce per month2-3 times per monthOnce per week2-3 times per week4-6 times per weekEvery day
12. I was so distracted by eating that I could have been hurt (e.g. when driving a car, crossing the street, operating machinery).

NeverLess than once a monthOnce per month2-3 times per monthOnce per week2-3 times per week4-6 times per weekEvery day
13. My friends or family were worried about how much I overate.

NeverLess than once a monthOnce per month2-3 times per monthOnce per week2-3 times per week4-6 times per weekEvery day
Patient informed Consent for Weight Loss Program
Semaglutide is a human based glucagon-like peptide-1 receptor agonist 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. BPC-157 is a stable gastric peptide which is stable in human gastric juice and can thus be effectively administered orally while maintaining its therapeutic and clinical potency.

While using Semaglutide + BPC-157, it is highly recommended that you:

• Eat a fibrous diet. Focus on fruits and vegetables that are high in fiber
• Eat small high protein meals as digestion is slowed down while on this medication
• Avoid foods high in fat as they take longer to digest
• Limit alcohol intake as this medication can lower blood pressure
• Drink at least 32oz of water a day to avoid constipation

Do not take this medication if:

• You have a personal or family history of medullary thyroid carcinoma (thyroid cancer)
• Multiple Endocrine Neoplasia syndrome type 2
• You are pregnant or plan to become pregnant while taking this medication
• You are diabetic and/or taking any medications related to lowering your blood sugar levels without speaking to your physician
• Specifically, 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 have a history of Pancreatitis
• You are allergic to BPC—157, Semaglutide or any other GLP-1 agonist such as: Adlyxin®, Byetta®, Byrdureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy®;
• 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.

Possible drug interactions : Anti–diabetic agents, specifically: Insulin and Sulfonylureas (e.g. g lyburide, glipizide, gl imepiride, tolbutamide ) due to the increased risk of hypoglycemia (low blood sugar). Do not take with other GLP-1 agonist medicines such as: Adlyxin®, Byetta®, Byrdureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy® (THIS IS NOT AN ALL—INCLUSIVE LIST). Other medications used in diabetes, please tell your provider about any medications that may lower your blood sugar.

Possible side effects: 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 reaction, including rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing. Report adverse side effects to your doctor or pharmacist. In the event of any emergency, call 911 immediately.
No Guarantees

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 of my life if I am to be successful.

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 in talking with my doctor regarding risks associated with the proposed treatment and regarding other treatments not involving the appetite suppressants.

By signing, I certify that I have read and understand the contents of this form. I am aware of the possible side effects and drug interaction and give my consent for treatment. I have informed the medical staff of any unknown allergies to drugs or other substances, and any past adverse reactions I've experienced. I have informed the staff of all medications and supplements I'm currently taking. I understand there are other ways and programs that can assist me in my desire to decrease my body weight and acknowledge that no guarantees have been made to me concerning my results.

I further understand that upon withdrawal from this program, I will not be entitled to a refund of any previously paid monies.
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 DOCTOR NOW BEFORE SIGNING THIS CONSENT FORM.
Date

MonthDayYear
Date
Date of Birth
Printed Name*
Signature*

Clear
Please submit this form online, or you can download, sign, and email it to info@blueskymd.com
Should be Empty:

Blue Sky MD Virtual Patient Registration Form

Health History

Weight Intake and History

Eating Habits in the Past Year

Patient informed Consent for Weight Loss Program

WARNING: