Weight Management Patient Form

Weight Management Questionnaire

Please complete this mandatory questionnaire to determine if you qualify for treatment. Please note: filling out this form does not constitute medical advice and does not establish any kind of patient-provider relationship. A patient-provider relationship is only formed after you have formally been onboarded as a patient by the treating provider.
Name

First NameLast Name
DOB

MonthDayYear
Date
Preferred name or nickname
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Contact Info
Emergency Contact
Relationship
Emergency Contact Phone
Please enter a valid phone number.
Primary Care Physician & Town
PCP Phone Number
Please enter a valid phone number.
Pharmacy & Town
Pharmacy Phone Number
Please enter a valid phone number.
Please list any drug allergies

Essential Policies
Please click on linked policies to review.

Health & Data Privacy Policy

Credit Card, Cancellation and No-Show Policy

Medication Policy

Telehealth Policy

Photo Policy and Permissions
Please check ALL boxes to confirm receipt and understanding of Essential policies.*

I have been provided the Patient Health and Data Privacy Policies at Essential Advanced Skincare and Medspa and understand that I have access to this information on their website or in the spa at any time. I understand and accept Essential's Privacy Policy.I have read, understand and agree to Essential's Medication Policy.I have read, understand and agree to Essential's Credit Card, Cancellation and No Show Policy.I have read, understand and agree to Essential's Telehealth Policy.
Photo Permissions
Please select the appropriate option for you; a selection IS REQUIRED.
Identification
Upload a copy of a valid identification like a Driver's License, Passport, or State ID.

Cancelof
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications from treatments received. I am aware that it is my responsibility to inform my provider of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Essential Advanced Skincare and Medspa and/or my provider from liability and assume full responsibility thereof. I understand the policies outlined above and consent to consultation and treatment.
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Date

MonthDayYear
Date
Should be Empty:

	Mother	Father	Sibling	Child	Grandparent	Aunt/Uncle
Obesity
Diabetes
Thyroid Cancer or Disease

Weight Management Questionnaire

Contact Info

Medical History

Medications

Allergy History

Family History

Social History

Weight History

Nutritional History

Essential Policies

Photo Permissions

Identification