TXWOUNDX.COM-WEIGHT MANAGEMENT

PATIENT INFORMATION
Patient’s Name*

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Emergency Contact Information:
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Relationship:
Physician:
Referring Physician:
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Primary Insurance:
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*If Patient is a minor or Power of Attorney is involved in care:
Parent/Guardian Name:
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Parent/Guardian Name:
Relationship:

CONSENT FOR TREATMENT
I hereby give my permission for Lammons Healthcare & Associates, PLLC and its associates or assistants to examine and render treatment as may be necessary in the diagnosis and/or treatment of my weight management and release related information to my physician and/or emergency medical personnel as required by law. Treatment may include examination, medication administration, and other various weight management related/reasonable therapies.
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AUTHORIZATION AND CONSENT FOR USE OF RECORDING DEVICES FOR MEDICAL DOCUMENTATION
Lammons Healthcare & Associates, PLLC (including WoundX) is committed to enhancing the accuracy, efficiency, and quality of medical documentation. As part of this process, recording devices may be used to capture verbal dictation of SOAP (Subjective, Objective, Assessment, and Plan) notes, which are then transcribed and entered into the Electronic Medical Record (EMR). This method improves workflow efficiency, ensures accurate and timely documentation, and enhances overall patient care.

By signing below, you acknowledge and agree to the following:

1. Authorization for Recording: You authorize Lammons Healthcare & Associates, PLLC and its designated providers to use audio recording devices to document SOAP notes for medical purposes. These recordings are intended solely for clinical documentation and will not be shared, distributed, or used for any purpose beyond patient care and recordkeeping.

2. Confidentiality & HIPAA Compliance: Lammons Healthcare & Associates, PLLC adheres to all HIPAA regulations and confidentiality standards to protect patient information. Recordings will be securely stored and deleted upon successful transcription into the EMR.

3. Efficiency & Accuracy: The use of recording technology streamlines documentation, reducing administrative burdens and ensuring the correct and complete logging of medical notes, leading to improved patient outcomes.

4. Limited Use & Access: Access to recorded dictations will be restricted to authorized medical personnel responsible for transcription and documentation. No recordings will be used for training, research, or any other non-clinical purpose without prior written consent.

5. Right to Revoke: You have the right to withdraw this authorization at any time by providing written notice to Lammons Healthcare & Associates, PLLC. However, withdrawal will not apply to recordings already transcribed and incorporated into the medical record.

6. Acknowledgment of Consent: You understand that this authorization is voluntary and that declining or revoking consent may require alternative documentation methods.

By signing below, you acknowledge that you have read and understand this authorization and consent to the use of recording devices for SOAP note documentation.
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PHOTO, VIDEO, AND AUDIT CONSENT
I hereby consent to allow Lammons Healthcare & Associates, PLLC., its agents, representatives, employees, successors, or assign to photograph, and/or videotape. I further grant to Lammons Healthcare & Associates, PLLC the right and permission to copyright, reproduce, broadcast, telecast, and/or publish the photograph(s), film, videotape, recordings, endorsement, or copy in which I may include in whole or part or composite form for utilization in diagnostics, documentation, treatment, and/or teaching or demonstration purposes, or art purposes, trade, website use, advertising, and all advertising media, or for any lawful reproduction purpose.

I understand that these images will be stored in a secure manner to protect them from unintended use by unauthorized parties. I understand and agree that these images/recordings may include inferring information regarding medical conditions and/or treatment at the Lammons Healthcare & Associates, PLLC locations and affiliated entities.

I understand and agree that I have the right to rescind this agreement and Lammons Healthcare & Associates, PLLC., will not make any additional media placement of my images or recordings. I also understand that Lammons Healthcare & Associates, PLLC., will not withdraw any media where my images or recordings have already been placed. To rescind approval, I must submit a request in writing to Lammons Healthcare & Associates, PLLC.
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AUTHORIZATION TO RELEASE INFORMATION
I, blanks hereby authorize Lammons Healthcare & Associates, PLLC., to release any information regarding medical treatment for the purpose of validating and determining benefits payable in connection with claims. I may revoke consent for the above item at any time in writing. I also understand that there is a $25 non-refundable fee for any requested medical records or the completion of any forms, including FMLA, and others.
Signature of Patient or Guardian:*

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PRIVATE INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS AND PRIVACY PRACTICES
I, blanks* the undersigned, authorize payment of medical benefits to Lammons Healthcare & Associates, PLLC. for any services furnished to me by the physician. I understand I am financially responsible for any amount not covered by my insurance policy. I also authorize Lammons Healthcare & Associates, PLLC. to release to my insurance company, referring physician, insurance companies and other consultants on my case information concerning health care advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claims of benefits.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
By signing this document, I acknowledge that I have been given the opportunity to read the Notice of Privacy Practices of Lammons Healthcare & Associates, PLLC.
NOTICE OF PRIVACY PRACTICES
Protected Health Information may be disclosed to insurance companies, managed care organizations, or referring physicians in the course of treatment, payment, or healthcare operations. When information is disclosed to another entity, it may be subject to redisclosure by the recipient and may no longer be protected by the HIPAA Privacy Rule. You have the right to refuse or restrict disclosure of your information.
Signature:*

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CONSENT TO SEMAGLUTIDE OR TERZEPATIDE TREATMENT
Indications and Limitations of Use

Semaglutide/Terzepatide is an injectable prescription medication for adults with obesity (BMI ≥30) or overweight (excess weight) (BMI ≥27) who also have weight-related medical problems used with a reduced-calorie meal plan and increased physical activity.

Semaglutide/Terzepatide has not been studied in patients with a history of pancreatitis. Consider other antidiabetic therapies in patients with a history of pancreatitis.

Semaglutide/Terzepatide is not a substitute for insulin. Semaglutide/Terzepatide is not indicated for use in patients with type 1 diabetes mellitus or for the treatment of patients with diabetic ketoacidosis.

Contraindications
Semaglutide/Terzepatide is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2, and in patients with known hypersensitivity to Semaglutide/Terzepatide or to any of the product components.

Warnings and Precautions

● Risk of Thyroid C-Cell Tumors: Patients should be referred to an endocrinologist for further evaluation if serum calcitonin is measured and found to be elevated or thyroid nodules are noted on physical examination or neck imaging.
● Pancreatitis: Acute and chronic pancreatitis have been reported in clinical studies. Observe patients carefully for signs and symptoms of pancreatitis (persistent severe abdominal pain, sometimes radiating to the back with or without vomiting). If pancreatitis is suspected, discontinue Semaglutide/Terzepatide promptly, and if pancreatitis is confirmed, do not restart.
● Diabetic Retinopathy Complications: In a 2-year trial involving patients with type 2 diabetes and high cardiovascular risk, more events of diabetic retinopathy complications occurred in patients treated with Semaglutide/Terzepatide (3.0%) compared with placebo (1.8%). The absolute risk increase for diabetic retinopathy complications was larger among patients with a history of diabetic retinopathy at baseline than among patients without a known history of diabetic retinopathy. Rapid improvement in glucose control has been associated with a temporary worsening of diabetic retinopathy. The effect of long-term glycemic control with Semaglutide/Terzepatide on diabetic retinopathy complications has not been studied. Patients with a history of diabetic retinopathy should be monitored for progression of diabetic retinopathy.
● Hypoglycemia: The risk of hypoglycemia is increased when Semaglutide/Terzepatide is used in combination with insulin secretagogues (e.g., sulfonylureas) or insulin.
● Acute Kidney Injury: There have been post marketing reports of acute kidney injury and worsening of chronic renal failure, which may sometimes require hemodialysis, in patients treated with GLP-1 receptor agonists. Some of these events have been reported in patients without a known underlying renal disease. A majority of the reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration. Monitor renal function when initiating or escalating doses of Semaglutide/Terzepatide in patients reporting severe adverse gastrointestinal reactions.
● Hypersensitivity: Serious hypersensitivity reactions (e.g., anaphylaxis, angioedema) have been reported with GLP-1 receptor agonists. If hypersensitivity reactions occur, discontinue use of Semaglutide/Terzepatide; treat promptly per standard of care, and monitor until signs and symptoms resolve. Use caution in a patient with a history of angioedema or anaphylaxis with another GLP-1 receptor agonist.

Tell your provider if you have a history of any of those listed.

Adverse Reactions
The most common adverse reactions, reported in ≥5% of patients treated with Semaglutide/Terzepatide are nausea, vomiting, diarrhea, abdominal pain, and constipation.

Drug Interactions
The risk of hypoglycemia may be lowered by a reduction in the dose of the secretagogue or insulin. Semaglutide/Terzepatide causes a delay of gastric emptying and has the potential to impact the absorption of concomitantly administered oral medications, so caution should be exercised.

Use in Specific Populations
There is limited data with Semaglutide/Terzepatide use in pregnant women to inform a drug-associated risk for adverse developmental outcomes. Discontinue Semaglutide/Terzepatide in women at least 2 months before a planned pregnancy due to the long washout period for Semaglutide/Terzepatide.

I understand that if I experience any negative side effects that I am to stop the drug immediately and contact my prescriber. I have had ample time to have my questions answered and consent to the use of Semaglutide/Terzepatide.
Patient Name:*
Patient Signature:*

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Date:*

MonthDayYear
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Should be Empty:

	Yes	No	Family
Diabetes
Chest Pain
High Blood Pressure
Heart Disease
Heart Attack
Stroke/CV A
Heart Palpitations
Pacemaker
Headaches
Kidney Problems
Seizures
Cancer
Osteoporosis
Bowel/Bladder Abnormalities
Urine Leakage
Blood Virus (HIV, Aids)
Asthma or Breathing Difficulties
Liver/Gallbladder Problems
Eye Disorders
COPD/Lung Issues
Blood Clotting
Lymphedema
Smoking/ Tobacco Use
Allergies to Medication
Environment Allergies
Other Allergies
Are you on Blood Thinners?
Hernia
Are you pregnant?
Metal Implants
Dizziness/Fainting
Bone Fracture
Skin Abnormalities
Sinus Problems
Sexual Dysfunction
Nausea/Vomiting
Ringing in your ears
Rheumatoid Arthritis
Kidney Stones
Recent Cardiology Workup
Other Implanted Devices
Anxiety or Depression
Radiation or Chemotherapy
Thyroid cancer
Thyroid problems
Pancreatic Cancer
Pancreatic Problems

PATIENT INFORMATION

Emergency Contact Information:

Physician:

Primary Insurance:

Secondary Insurance:

*If Patient is a minor or Power of Attorney is involved in care:

MEDICAL HISTORY

PHARMACY (list pharmacy most frequently used for prescriptions)

TOBACCO HISTORY

ALCOHOL AND DRUG HISTORY

CONSENT FOR TREATMENT

AUTHORIZATION AND CONSENT FOR USE OF RECORDING DEVICES FOR MEDICAL DOCUMENTATION

PHOTO, VIDEO, AND AUDIT CONSENT

AUTHORIZATION TO RELEASE INFORMATION

PRIVATE INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS AND PRIVACY PRACTICES

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT

NOTICE OF PRIVACY PRACTICES

CONSENT TO SEMAGLUTIDE OR TERZEPATIDE TREATMENT