Health History

Patient Gender*

Patient Name*

First NameLast Name

Patient Birth Date*

MonthDayYear

Age*

Address. Services are for For Pennsylvania Residents Only *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred Phone Number *

Area CodePhone Number

Patient Height (ex5.7)*

Patient Weight (in lb)*

Patient E-Mail*

Reason for visit:*

ex: Routine Check-up

Please tell us your weight loss goals. As well as do you want to participate in a particular program: like Local Pick Up or Microdosing? Would you be interested in a multi-month supply of medication? If you are unsure, no worries, we will discuss everything at your appointment. *

Referred by someone? Enter their name for credit*

Please list if you have any drug allergies*

ex: Penicilin

Have you ever experienced allergic reaction, specifically anaphylaxis?*

Please list your current medications*

Have you ever had (Please check all that apply)*

Any surgeries?

Have you tried to get weight loss medication from another provider?*

How much weight do you want to lose? *

Are you or have you been on a weight loss drug, if so what ?*

Was it a GLP-1 med? Are you still taking?

Have you had weight loss surgery, if yes, what kind and when?*

Have you ever been diagnosed with an eating disorder?*

Have you taken hormone replacement before?*

Do you have current lab work that you would like to share?

Preferred pharmacy name and phone number *

Exercise

Never1-2 days3-4 days5+ days

Eating following a diet

I have a loose dietI have a strict dietI don't have a diet plan

Alcohol Consumption

Caffeine Consumption

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day

Do you smoke or vape?

NoYes

Include other important comments regarding your Medical History, if nothing, type N/A*

I understand insurance is not accepted for services or medications at Revive Infusion & Injection Service *

I understand refunds will not be issued for any services or medications at Revive Infusion & Injection Services*

I understand that it is my responsibility to follow up with Revive Infusion & Injection Services either in clinic, via telehealth, or asynchronous visits( example texting and phone calls)on a regular basis. I will not adjust my dose without approval and consent from my provider. I will text any questions or concerns to 814-433-2632 please initial and date as acknowledgement.*

Initial and date

Patient Informed Consent - Weight Loss

This Informed Consent and Indemnification Clause ("Agreement") is entered into between the undersigned patient ("Patient") and Brooke Grassmyer, FNP-C ("Provider") and Revive Infusion & Injection Services LLC ("Clinic"). This Agreement pertains to the voluntary participation in a weight loss program that may involve the use of peptides, including but not limited to Semaglutide and Tirzepatide, as well as other weight loss medications at the discretion of the Provider. The program may include the use of compounded medications obtained from a reputable compounding pharmacy, and it is considered off-label use. The following terms and conditions are legally binding, and the Patient is required to provide initials as well as print full name, signature, and date to indicate understanding and acceptance:

1. Voluntary Participation: I understand and agree that my participation in this weight loss program is voluntary, and I have chosen to participate of my own free will.

2. Medication Administration: I understand that the medications provided in this program are to be self-administered by me, the Patient. The Provider is not responsible for medication administration errors by the Patient, including over or under-medication.

3. Home-Based Program: I acknowledge that this is a convenient home-based program, and medications will be sent to my home by the compounding pharmacy.

4. Prescription for Patient of Record: I understand that the prescribed medications are for my use only and may not be shared with others.

5. Initial Consultation: I understand that an initial consultation is required and may be conducted in-person at the Clinic or via telehealth, as determined by the Provider.

6. Health History Form: I acknowledge that a Health History form must be completed prior to the initial consultation, and I will notify the Provider of any changes in my health history going forward.

7. Optional Follow-Up Visits: I understand that follow-up visits are optional, and I may choose to attend them as needed.

8. Weekly Check-Ins: I agree to participate in weekly check-ins with the Provider via text at 814-433-2632 as a part of this program.

9. Timely Reporting of Issues: I will inform the Provider promptly of any adverse effects, concerns, or issues related to my treatment and agree to follow any recommendations provided.

10. Diet, Exercise, and Medication: I will follow the diet, exercise, and medication dosing recommendations provided by the Provider.

11. Realistic Expectations: I understand that weight loss expectations should be based on my gender, age, metabolism, and health history. I acknowledge that the expected side effects of the prescribed medications have been explained to me, but there may be other potential, serious side effects. I accept and acknowledge these potential risks.

12. Not a Diagnosis or Treatment for Disease: I acknowledge that this weight loss program is not intended to diagnose or treat any disease, and I will consult my primary care physician (PCP) for any pre-existing or new health conditions.

13. No Responsibility for Outcomes: I agree that I cannot hold the Provider or the Clinic responsible for the outcomes of the voluntary use of the prescribed medications or the weight loss program.

14. Optional Laboratory Work: I understand that laboratory work is optional, and if I choose to obtain labs, I can pay cash or use my own insurance, and the labs will be performed at the Provider's chosen laboratory.

15. Contact Information: I may contact the Provider at any time at 814-433-2632 for questions or concerns.

16. Changes to Program Details: I acknowledge that program details, including medications and pricing, can change without notice, and I will be informed of any significant changes.

17. HIPAA Compliance: I understand that the Provider participates in HIPAA compliance, and for the privacy statement, I may request it in writing.

18. Treatment Termination: I acknowledge that treatment can be terminated by either the Patient or the Provider at any time without notification or cause.

19. Long-Term Treatment Goals: I understand that long-term treatment goals should be re-evaluated annually or sooner and scheduled as a follow-up appointment.
20. I will stop the use of this medication 2 weeks prior to undergoing any anesthesia.

By completing my health history paperwork, I acknowledge that I have read, understood, and agreed to the terms and conditions of this Agreement.

I have read the above informed consent*

YesNo

Signature

Health History - must complete

General Information

Medical History

Healthy & Unhealthy Habits