Weight Loss consent and forms

Patient's Name (printed)*

Weight Management Program Consent Form

I.authorize Heart 2 Heart Health and Wellness (H2HHW) contracted by Heart 2 Heart Family Practice PA healthcare providers and for whomever may be designated as the medical assistant(s), to help me in my weight-reduction efforts. I understand that my program may consist of a balanced deficit diet, a high protein low carb diet, increase in physical activity, instruction on behavior modification, and the use of anti-obesity medications (phentermine, lipotropic, GLP-1, GIP, etc

I understand that any medical treatment may involve risks as well as benefits I also understand that there are certain health risks associated with having excess weight or obesity. Risks associated with obesity management programs are usually temporary, reversible, and may include but are not limited to nervousness, sleeplessness, headaches, electrolyte abnormalities, dry mouth, gastrointestinal disturbances, weakness, fatigue, pancreatitis, psychological problems, gallstones, high blood pressure, rapid or slowing of the heartbeat and other heart irregularities, and risk of weight regain. These and other possible risks could, on occasion, be serious or even fatal. Risks associated with having obesity may include but are not limited to high blood pressure; diabetes; heart attack; heart disease; cancer; arthritis of the joints, including hips, knees, feet, and back; sleep apnea; and sudden death. I understand that these risks may increase with additional weight gain.

I understand that much of the success of the program will depend on my efforts and that there are no guarantees that my plan will be successful I also understand that obesity is a chronic, lifelong condition that will require permanent changes in eating habits, activity level, and behavior to be effective. understand that failing to show up for an appointment / have scheduled and confirmed represents a disruption to the operation of the clinic and medication wasted. Failure to show up ("NO-SHOW") for a pre-appointed injection may result in a wasted dose therefore reducing your 4 week coverage to 3 weeks, etc Failure to cancel at least one full business day prior to a scheduled visit will result in the need to pay for the missed visit, wasted products and prepayment for future services. You are responsible for full payment for services rendered or ordered No checks allowed- only cash and credit cards accepted. All credit cards are subject to a convenience fee.

Telehealth

I HEREBY REQUEST AND CONSENT TO THE ONLINE WEIGHT LOSS SERVICES TO BE PROVIDED BY COMPANY (Heart 2 Heart Health and Wellness) AND THE COMPANY PARTIES. I understand that telehealth involves the communication of my medical information, both orally, in writing, and visually, to physicians and other healthcare practitioners at other locations. I understand that the physician-patient relationship, if any, between myself, Company, and the Treating Professionals, is explicitly limited in nature to the Weight Loss Services, and nothing else. I further understand that, even if I have health insurance of any form, that the Consultation Services are private-pay and are likely not coverable by such insurance. I agree to NOT bill any insurer that may cover me for the Weight Loss Services, and acknowledge that Company and the Professionals will not be billing any 3rd party for the Consultation Services.

Telehealth

I understand that while the Professionals will make every attempt to accurately diagnose and treat my healthcare condition for which I am seeking a second opinion, there is still some inherent uncertainty and inaccuracy with delivering healthcare over the Internet. I accept that the “physical exam” portion of the online visits, if any, will be done via pictures, two-way audio/video consultation, questionnaire, relying upon my medical records, or otherwise, which agreed to be an appropriate prior examination made in good faith, though, in some other types of medical situations, such a methodology is not a “conventional” way of conducting a physical examination. I accept this, with all potential benefits and consequences, and deem this method of physical examination appropriate and complete.

I understand that I have the option to withhold or withdraw my consent to receive the Weight Loss Services via telehealth at any time, but that doing so will cause Company and the Professionals to discontinue providing future care or treatment, it being acknowledged that Company and the Professionals will only be treating me via telehealth methodologies. In such case, I understand that I will need to seek treatment elsewhere.

I understand the potential benefits of telehealth, which include having access to medical specialists and additional medical information and education without having to travel outside of my local health care community.
I understand the potential risks and consequences of telehealth, which include that because of my specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine appointment, and the telehealth care provider may not be able to accurately diagnose my condition due to limitations inherent in using a non-face-to-face encounter. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to telemedicine consultation is a face-to-face visit with a physician.
I understand that all laws about the confidentiality of medical information apply to telehealth information.
I understand that all laws about patient access to medical information and copies of medical records apply to telehealth records.
I understand that no images or information from the telehealth interaction that identify me will be given to researchers or other entities or parties not listed above without my consent, unless allowed by applicable law.

Weight Loss Services Specifically

PREGNANCY AND BREASTFEEDING: I UNDERSTAND THAT IF I AM PLANNING TO BECOME PREGNANT, AM CURRENTLY PREGNANT, BECOME PREGNANT, OR AM BREASTFEEDING, THAT I WILL: (A) ADVISE COMPANY AND THE COMPANY PARTIES OF THIS; AND (B) ASK MY OB/GYN OR PEDIATRICIAN IF THE TREATMENTS RECOMMENDED BY THE COMPANY PARTIES ARE ACCEPTABLE DURING THIS PERIOD OF TIME.

OUTCOMES NOT GUARANTEED: Neither Company nor the Professionals guaranty outcomes based on utilizing the Weight Loss Services or products or medicines associated with the Weight Loss Services. I acknowledge that my condition for which I am seeking treatment may get worse, and I am subject to the risks further described below, including risks that my condition may worsen. I agree that I will not be entitled to a refund or recompense from Company or the Professionals for any reason, including poor outcomes.

I understand that the fees that I pay Company and/or the Professionals DOES include the costs of any prescription drugs or medicines, or other courses of treatment, that may be recommended/prescribed by Company or the Professionals. I understand that I am wholly responsible for the payment of any such products, drugs or medicines or treatments.
I understand that all health care treatments can have potential adverse side effects and I accept responsibility for these potential adverse outcomes.
If adverse effects are noted, I understand that it is my responsibility to stop all treatments recommended by the Professionals, and to report any adverse side-effects to Company, the Professionals, my local doctor, and to go to the nearest Emergency Room if necessary.
I understand that it is my responsibility to contact my local primary care physician before starting any treatments, prescriptions,*** or implementing any Professionals’ Weight Loss Services suggestions, to make sure that my local doctor approves of the treatment regimen.
I understand that once the Professionals decide on the treatments and medications to be issued, if any, it is my responsibility to read and understand the risks and the side-effect profile of the medications and the adverse drug interactions of the medications and other medications I may be taking, to consult with my local doctor and pharmacist regarding the same, and ultimately to determine if the risks are acceptable to me.

Limited Nature of Relationship

I understand that I should not expect any services from Company or the Professionals outside of the limited Weight Loss Services.
I UNDERSTAND THAT COMPANY AND THE COMPANY PARTIES ARE NOT MY GENERAL OR SPECIALIZED PHYSICIANS/HEALTH CARE PROVIDERS, AND ARE ENGAGED FOR A LIMITED PURPOSE, AND I UNDERSTAND THAT I SHOULD FOLLOW-UP WITH MY PRIMARY CARE PHYSICIAN REGARDING ANY ISSUES THAT MAY ARISE DURING THE WEIGHT LOSS SERVICES.
TO THE EXTENT ALLOWABLE BY LAW, THE WEIGHT LOSS SERVICES ARE NOT INTENDED TO CREATE, NOR DO THEY CREATE, ANY PHYSICIAN-PATIENT RELATIONSHIP WITH COMPANY OR THE COMPANY PARTIES, EXCEPT FOR THE LIMITED PURPOSES OF PROVIDING WEIGHT LOSS SERVICES. I EXPRESSLY AGREE THAT THIS IS A LIMITED ENGAGEMENT. I EXPRESSLY AGREE THAT NEITHER COMPANY NOR THE COMPANY PARTIES HAS AN OBLIGATION TO TREAT ME OR OTHERWISE COUNSEL ME REGARDING ANY CONDITIONS THAT MAY BE DISCOVERED OR EVALUATED OR DISCUSSED DURING THE CONSULTATION SERVICES. I UNDERSTAND THAT THE COMPANY AND THE COMPANY PARTIES DO NOT GUARANTEE THE ACCURACY, COMPLETENESS, USEFULNESS, OR ADEQUACY OF THE WEIGHT LOSS SERVICES FOR ANY TREATMENT, DIAGNOSIS, OR OTHER PURPOSES.
I WILL INFORM COMPANY AND THE COMPANY PARTIES OF ANY CONDITION THAT WOULD LIMIT MY ABILITY TO HAVE WEIGHT LOSS SERVICES OR THAT WOULD BE RELEVANT TO THE WEIGHT LOSS SERVICES ITSELF.

I have read and fully understand this consent form and it has been fully explained to me. My questions have been answered to my complete satisfaction I have been given all the time that I need to carefully read and understand this form.

(initials) By my Initials, I acknowledge that I have had an opportunity to review Heart 2 Heart Family Practice PA HIPPA Policy and also acknowledge that if I should request a copy, a copy will be provided to me.

Witness

Patient Signature*

Date

Patient Signature (or signature of person with authority to consent for patient)

PLEASE INITIAL EACH BOX BELOW

Risk of Thyroid C cell Tumors: If serum calcitonin is measured and found to be elevated, the should be further evaluated. Patients with thyroid nodules noted on physical examination or should also be further evaluated*

Acute Pancreatitis: Acute pancreatitis, including fatal and non fatal hemorrhagic or pancreatitis, has been observed in patients treated with GLP 1. Observe patients carefully and symptoms of pancreatitis (persistent severe abdominal pain, sometimes radiating to the or without vomiting). Medication will be discontinued*

Acute Gallbladder Disease: Substantial or rapid weight loss can increase the risk of*

Hypoglycemia: Adult patients with type 2 diabetes on an insulin secretagogue (eg. a or insulin may have an increased risk of hypoglycemia. The risk may be lowered by a in the dose of insulin secretagogues or insulin.*

Heart Rate Increase: Report palpitations or feelings of a racing heartbeat while at rest during Medication will be discontinued in patients who experience a sustained increase in resting rate*

Renal Impairment: Acute renal failure and worsening of chronic renal failure, which may require hemodialysis, have been reported, usually in association with nausea, vorniting, or dehydration. Use caution when initiating or escalating doses in patients with renal*

Acute Kidney Injury: Patients with renal impairment may be at a greater risk of acute kidney Monitor renal function when initiating or escalating doses in patients reporting severe adverse reactions and in patients with renal impairment reporting any adverse reactions that to volume depletion*

Hypersensitivity Reactions: If a hypersensitivity reactions (eg. anaphylaxis and angioedema) please discontinue medication and promptly seek medical advice*

Suicidal Behavior and Ideation: Please report emergence or worsening of depression, suicidal or behavior, and/or any unusual changes in mood or behavior. It's contraindicated in patients history of suicidal attempts or active suicidal ideation*

I certify that I am not pregnant and or on birth control as am aware that these medications are recommended in pregnancy and can cause fetal harm.*

Patient's Name (printed)*

The most common adverse reactions, reported in 25% are nausea, diarrhea, constipation, vorniting, injection site reactions, headache, hypoglycemia in patients with type 2 DM, dyspepsia(indigestion), fatigue, dizziness, abdominal pain, increased lipase, upper abdominal pain, pyrexia(fever), and gastroenteritis, I certify that I am not pregnant and or on birth control as am aware that these medications are not recommended in pregnancy and can cause fetal harm.

Patient Signature*

Date

Patient Signature (or signature of person with authority to consent for patient)

HEART2HEART FAMILY PRACTICE HEALTH AND WELLNESS SERVICES

I give my consent for Heart 2 Heart Family Practice to use any photos or quotes for express purposes of advertising use, public relations brochures, use in clinic displays, displays at public events. I understand that his photo or quote will not be sold to any

Signature*

Date

Heart 2 Heart Health and Wellness

Weight and Health Questionnaire

Name*

Date

Age*

Birth Date*

Date

Preferred Phone Number*

Email*

example@example.com

Marital Status

Occupation

Work Hours

Highest Level of Education

Primary Language: Englis, Spanis, Other -please list

Smoking Status: Never , Former, Current *

General Health Information List any health problems and physical limitations:

List any health problems and physical limitations*

List any allergies /intolerances*

List any medication, viatmins and herbals with dosages* Type a label* *
*

List any medications, vitamins, and herbals that are taken / include dose and frequency*

How do you rate the stress in your life, 10 being the highest?

1-34-56-910+

How do you cope with stress?

List any cultural or religious practices 'related to your health or diet

How do you rate your readiness to make lifestyle changes, 5. being the most ready?

How do rate your confidence to make lifestyle changes, 5 being the most ready

Current Weight*

Height*

What was your lowest and highest adult weight?*

Describe any weight changes (gain or loss) In the past 2 years*

Have you dieted in the past? if so what programs or diets have you done?*

What makes it hard for you to lose weight and keep It off?*

What has helped you lose weight?

How much welght would you like to lose?*

How will you benefit from: this weight loss?

Physical Activity Information:

What Is the most physically active thing you do In a day?

What, if any, regular exercises do you do?

How many days a week?

How many minutes per day?

At what level' of Intensity (light, moderate, or high)?

What time(s) of day can you fit exercise into your schedule?

List any physical limitations to exercising

In the box below fill in your typical day's food/meal intake for Breakfast, Lunch,Dinner and Snack*

How often do you eat out at restaurants/fast food?*

Who does the grocery shopping?

Who plans and prepares the meals at home?

What are 1 or 2 things you would like to change with your diet?

Client Signature*

Date

BMI