Medical History Form

Patient information will be kept confidential except as is necessary to provide services to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories as is necessary and appropriate for your care. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information. 

 

It is the policy of this office to remind patients of their appointments. We may do this by telephone, email or text message. 

This practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.

You agree to bring any concerns or complaints regarding your privacy to the attention of the office manager or medical professional.

Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.

We agree to provide patients with access to their records in accordance with state and federal laws. 

We may change, add, delete or modify any of these provisions to better serve the needs of both the practice and patient.

I, do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward. 

 

 

NO SHOW POLICY

We kindly request a minimum of 24 hours' notice for any cancellations of your scheduled appointment. 

Upon your first no-show, a $79 fee will be charged to your account. Upon your second no-show an additional $79 fee will be charged to your account. If you have no-showed two or more times, The Beauty Bar reserves the right to discharge you from the practice. This policy applies to new and established patients and will be charged directly to the patient/guarantor. These charges must be paid before you are seen again. 

Patient Consent for weight loss therapy and treament with The Wellness Center at the Beauty Bar LG

Services must be paid for at the time of service. 

We do not file insurance but if you would like to seek insurance reimbursement, we would be happy to provide you with itemized invoices that you can submit to your insurance company. 

Phentermine and Vyvanse are considered a controlled substance. I agree that I will take my medications as prescribed. I agree to follow my medical providers instructions. I also agree that I will not sell or share my prescriptions to other individuals. 

I understand that treatments used at The Wellness Center at the Beauty Bar LG might not be considered a medical necessity. Treatments rendered are for the purpose of improving your quality of life through hormone restoration, nutritional and supplemental counseling, and weight loss treatment. 

I agree that if I am having any sde effects or become sick, that I will follow up with my primary care provider or go to an urgent care or emergency department. 

I acknowledge that The Wellness Center at the Beauty Bar LG and J.R. Campbell, APRN, FMP-C are not my primary care provider unless I elect them so. I agree that I will continue with routine care through my primary care provider and notify them of treatments prescribed at The Wellness Center at the Beauty Bar LG. 

I understand that there are no refunds for services or products rendered. We cannot accept back used medications once they have been dispensed per state regulation. 

I understand that having an appointment with The Wellness Center at the Beauty Bar LG does not necessarily entitle me to being issues a prescription for hormone replacement, weight loss medication or additional medications. Every individual is different, at it is at the medical providers discretion to issue a prescription. 

I acknowledge that I have been advised of the risks and benefits of treatment. I also acknowledge that I have been advised of possible complications and side effects. I understand the risks, benefits, complications, and side effects of treatment. 

I am voluntarily requesting treatment with The Wellness Center at the Beauty Bar LG and J.R. Campbell, APRN, FNP-C in regards to weight loss therapy as determined by a mutial decision between myself and the medical provider even if my hormone leves are considered to be in normal range for my age based off of other medical society recommendations and guidelines or if I am just considered overweight and not obese. 

I do not hold any medical practitioner of The Wellness Center at the Beauty Bar LG responsibile for performing age-related preventive care. I agree that I will follow up with my primary care provider to obtain these screenings and I hold The Wellness Center at the Beauty Bar LG and J.R. Campbell, APRN, FNP-C harmless if any adverse event occurs during my treatment. I will ensure that my primary care provider provides the results of such screenings to The Wellness Center at the Beauty Bar LG as this could change the treament prescribed to me.