GLP-1 Medical History Consent Forms -JN

Last*

First*

Address*

City*

State*

Zip code*

Shipping address (if different from above)

email address*

Cellular Phone*

Date of Birth*

Driver's License /State ID #*

ID state of issue*

Height*

weight*

Please list any medications you are currently taking including vitamins and dietary supplements

Please list any known drug/ food allergies*

Please list any surgeries/ hospitalizations (date and describe circumstances)

Date

Abnormal weight gain

yesno

Decreased ability to sleep

yesno

if you need bloodwork, we charge an bloodwork fee (Includes blood draw and Dr consultation) before we order your labs. There will be a charge for the Dr consult if you provide all labs requested by Endless Vitality. ***I authorize Endless Vitality to charge my credit card and keep my card on file for future payments, to include payments for a monthly treatment plan of my choice, automatically charged each month while signed up for the program as we dispense medication. At any time, I would have he option to discontinue my program, I understand that I need to notify Endless Vitality to cancel further monthly credit card charges.

Patient Signature*

Date*

Date

1. This is my consent form for Endless Vitality and any physician or medical staff who is working with the company, to begin treatment for weight management, peptides, vitamin therapy (e.g. B12), or other treatment provided.*

initial or sign here

2. I understand there is no warranty or guarantee as to my individual results and that my condition may return or become worse when on therapy or after stopping therapy.

initial or sign here

3. I understand that I am resposnible for obtaining a physical exam by my primary care physician.

initial or sign here

4. you have diabetic ketoacidosis?*

yesno

5. Do you have a history of pancreatic or gall bladder disease?*

yesno

6. Do you have a personal or family history of medullary thyroid carcinoma (type of thyroid cancer)*

yesno

7. Do you have multiple endocrine neoplasia type 2 (tumors in the glands)*

yesno

The Patient accepts and agrees to the following: - I understand that the medication(s) I have purchased are prescribed to me based on diagnosis derived from my submitted medical history form and consultation. They are to be based exclusively for treatment of these diagnoses. -I will immediately report any adverse side effects related to the use of my medication to Endless Vitality and discontinue use until advised to resume usage. -I will safeguard my medications from loss or theft. -I will not share, sell or trade my medication for money, goods or services. -I agree that I will use my medication at the prescribed rate and dosage. -I will not attempt to obtain scheduled GLP-1 medications illegally or from any other health care practitioner without disclosing my current medication usage. I understand that it is against the law to do so.

I have had an opportunity to discuss all of the above items with Endless Vitality and its medical practitioners. I have also informed them of my complete past medical health and surgical history including ALL serious problems and/or injuries. All of my questions have been answered in full and I understand each point I have initialed above. All of the risks, benefits, and alternatives to testosterone replacement therapy have been answered fully.

Signature*

Date*

Date

Patient Name (printed)*

The Patient accepts and agrees to the following: - I understand that the medication(s) I have purchased are prescribed to me based on diagnosis derived from my submitted medical history forma and consultation. They are to be based exclusively for treatment of these diagnoses. -I will immediately report any adverse side effects related to the use of my medication to Endless Vitality and discontinue use until advised to resume usage. -I will safeguard my medications from loss or theft. -I will not share, sell or trade my medication for money, goods or services. -I agree that I will use my medication at the prescribed rate and dosage. -I will not attempt to obtain scheduled GLP-1 medications illegally or from any other health care practitioner without disclosing my current medication usage. I understand that it is against the law to do so.

I have had an opportunity to discuss all of the above items with Endless Vitality and its medical practitioners. I have also informed them of my complete past medical health and surgical history including ALL serious problems and/or injuries. All of my questions have been answered in full and I understand each point I have initialed above. All of the risks, benefits, and alternatives to testosterone replacement therapy have been answered fully.

Signature*

Date*

Date

Patient Name (printed)*

Patient Name*

DOB*

I wish to be called/text on cellular phone*

yes

(check all that apply) regarding care and follow up.

The best telephone numbers(s) to reach me are:

Other Phone

I want relevant medical information (i.e. lab results, biopsy results) on my answering

machine or voice mail.*

I doI don't

want relevant medical information shared with the person who may answer the

telephone. The name(s) of the individual(s) with whom you may leave pertinent information are:

Patient Signature*

Date*

Date

I hereby authorize Endless Vitality to access your medical/ medication history from third party sources (i.e. pharmacies

Signature*

Date*

Date

Patient Name (printed)*

I understand that I am consenting to an elective treatment/procedure/surgery that is not urgent or emergent.

I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact, and as a result, federal and state health agencies recommend social distancing. I understand that my doctor listed below has put in place reasonable safety measures to help reduce the spread of COVID-19.

I understand that even if I have received a negative COVID-19 test result, the test may have failed to detect the virus, orI

may have become infected after I took the test. I understand that even if I do not have any symptoms, I may have a COVID-19 infection, and that having the electivetreatment/procedure/surgery can lead to a higher chance of complication and death.

I understand that exposure to COVID-19 before, during, and after my treatment may result in the following: a positive COVID-19 diagnosis, extended isolation, additional tests, and hospitalization, up to and including: the need for treatment in intensive care (ICU), short-term or long-term intubation, other complications, and death.

I understand that COVID-19 may cause additional risks, some of which may not be known at this time.

I understand that this elective treatment may put me at increased risk for becoming infected with COVID-19. By consenting to this consent form, I accept that risk and give my permission to proceed with treatment.

I have been given the choice to have my treatment at a later date. I understand the potential risks of delaying and want to proceed.

I have read this consent or someone has read it to me.

Date*

Date

Patient Name (printed)*

Signature*

CREDIT CARD AUTHORIZATION

HIPAA CONSENT TO LEAVE MESSAGE

MEDICATION HISTORY AUTHORITY