HIPAA Medical History Form

Full Name/Nombre

First NameLast Name

Date of Birth/Fecha de Nacimiento

Phone/Telefono

Do you currently have or have had any of the following: Tienes ahora o has tenido algunos de las enfermedades abajo:

Are you currently taking any medication? Estas tomando algun medicamento?

Yes/SiNo/No

Yes/Si Medication/Medicamento

What is your Gender?

MaleFemale

Do you have any medication allergies? Tienes alguna alergia?

YesNoNot Sure

If yes/si list allergies/Lista alergias

Current Weight/Peso Actual

Goal Weight/Peso Ideal

Address/Direccion

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

1.This document is intended to serve as informed consent for Serenity Medspa & Wellness LLC weight loss program with injectable medication. My consent and authorization for this treatment is strictly voluntary.

2. I have informed the Nurse Practitioner (NP) of any known allergies to medications, substances, all current medications, supplements and my complete medical and family history.

3. I am not aware that I am pregnant. I am not currently breastfeeding.

4. I understand that I have the right to be informed of the treatment, any feasible alternative options, and the risks and benefits.

5. I authorize Serenity Medspa & Wellness LLC to take photographs during my treatment and use them for educational and marketing purposes.

6. I understand that:

The treatment involves a small injection needle into my abdomen area with the prescribed solution.
I understand the risks and benefits of self injecting and have had the opportunity to have all of my questions answered by a medical professional.

7. My signature on this form affirms that I have given my consent to partcipate in Serenity Medspa & Wellness LLC weight loss program and take the medication as prescribed.

8. I understand that this treatment is elective and that payment is my responsibility. Payment in full for all treatments is required at the time of initiating treatment and is non-refundable.

My signature below confirms that:

1. I understand the information provided on this form and agree to all of the statements made above.

2.The treatment has been adequately explained to me by the Nurse Practitioner.

3. I have received all of the information necessary to make an informed consent to treatment.

I have read and understand the above medical history questionnaire. I acknowledge that all the answers have been recorded truthfully and will not hold any staff member responsible for any errors or omissions that I have made in the completion of this form.

SignatureFirma