STEP 2 - Medical History and Consent Form

Medical History and Consent Form

(973) 960-0268 | info@renewme-wellness.com | www.renewme-wellness.com
Medical History Intake
IMPORTANT:

Please fill out this form to the best of your knowledge prior to your scheduled appointment. Inaccurate information may result in the inability to provide you with the appropriate medication or treatment.

If you have any questions or need assistance, do not hesitate to contact us at info@renewme-wellness.com

Thank you for choosing RenewMe Wellness LLC for your healthcare needs.
Eligibility Confirmation:
Are you a New Jersey resident OR are you willing to be in New Jersey at the time of your scheduled telemedicine consultation? If your response to the residency question is “NO,” unfortunately, you do not meet the criteria for our services. We are licensed exclusively to serve patients who are based in New Jersey.*

Yes
Do you have Type 1 Diabetes? If yes, you are NOT a candidate for Semaglutide/Tirzepatide.*

No
I agree to verify my identification by showing a valid ID at the beginning of my scheduled appointment.*

Yes
Are you over the age of 18 and do not require a parent or guardian for this consultation?*

Yes
Personal Information:
Name*

First NameMiddle NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Ethnicity*

Hispanic or LatinoNot Hispanic or Latino
Race*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is your address the same as your Shipping Address

Yes
Confirm Shipping Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Weight Information:
Which medication are you interested in today?*

SemaglutideTirzepatide
What goals are you trying to accomplish?

Lose weightImprove general healthLook betterImprove confidenceIncrease energyOther
Current weight*
Current Height*
What have you tried in the past?

ExerciseDietingWeight loss supplementsIntermittent fastingWeight loss programsWeight loss injectablesOther
What is your weight loss goal?

Lose 1-20 lbsLose 21-50 lbsLose over 50 lbsMaintain
Social History:
Do you smoke?*

YesNo
If you answered “Yes” to smoking, please provide details:
Number of packs per day
Duration (years)
Do you consume alcohol regularly?*

YesNo
Weekly Amount:
Activity Levels:

SedentaryLightly ActiveModerately ActiveVery Active
Women’s Health (please check all that apply and provide additional details if necessary):*

Doesn't ApplyTrying to get pregnant or planning pregnancy in the near futureCurrently pregnant or possibility of being pregnantBreastfeedingOn hormone replacement therapyOn birth controlPost-Menopausal
Others: please specify
Medical History: Please check all that apply and provide additional details where necessary.*

Doesn't ApplyHeart DiseaseDisease of the arteriesHigh blood cholesterolAnemia or any blood disorderStrokeThyroid CancerParathyroid or Adrenal Gland IssuesDiabetes or abnormal blood sugarDeep Vein ThrombosisGallstones or Gallbladder DiseaseKidney Problems including CKDAsthma or other breathing problemsPancreas IssuesDigestion problems, stomach or gastric ulcerLiver ProblemsNeurological IssuesEating DisordersDepressionAnxietySubstance AbuseArthritisUncontrolled High Blood PressureSeizure DisordersCancer

List any hospitalizations, including dates and reasons for hospitalization (including surgeries):

	Date of Hospitalization	Reason for Hospitalization/ Surgery
1
2
3
4
5
6

Do you suffer from any other condition you feel we should be aware of?*

YesNo
If yes, please explain
Have you or a family member been diagnosed with either of the following?*

Multiple Endocrine Neoplasia Syndrome Type 2 (MEN2)Medullary Thyroid CarcinomaDoesn't Apply
If yes, please explain
Family Medical History:
Have you or your blood relatives had any of the following? (Include grandparents, aunts, and uncles; exclude cousins, relatives by marriage, and half-relatives)

Heart DiseaseDiabetesCancer
Other
Medications:
Are you currently taking any of the following medications?

Blood Thinning Medication (i.e., Aspirin/Warfarin)BexaroteneGemifloxacinDiabetes Medications
If yes, please explain:

List any prescription medications you are now taking.

	Medication	How Often	Purpose
1
2
3
4
5
6

List any self-prescribed medications, dietary supplements, or vitamins you are now taking.

	Medication	How Often	Purpose
1
2
3
4
5
6

Are you allergic to any of the following?

GLP-1 Receptor AgonistsSodium PhosphateAdhesives / Latex
Are you allergic to any other medications, latex, or other substances? If yes, please list. If not, write “N/A”. If so, please describe*
Additional information to help us assist you
If you have any recent bloodwork, you would like to share, please upload file here.

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Privacy Policy:
- Should I provide an email address or cellular phone number, I consent to receive unsecured healthcare communications and appointment reminders at these contacts. I understand that while the practice does not charge for this service, standard text messaging rates and cellular phone charges may apply as per my wireless plan.
Telemedicine consent:
- I authorize and agree that RenewMe Wellness LLC services involve the use of telemedicine or telehealth equipment and interaction with providers that are outside of my physical presence.
- I will ensure access to the necessary technology for efficient telemedicine appointments.
- I consent to the use of telemedicine for healthcare services and understand the associated risks and limitations.
- I agree to notify the provider of my location honestly and to notify them of any changes before any tele-health visit.
- I agree to verify my identification by showing a valid ID at the beginning of my scheduled appointment.
Acknowledgment:
- By signing below, I acknowledge that I have read and understood the information on this form, and that all the information I have provided is accurate and to the best of my knowledge. I understand that it is my responsibility to inform RenewMe Wellness LLC and/or providers of any changes to my medical history.
- This consent is ongoing and will remain in effect even after a diagnosis is made and treatment begins.
Consent for Telemedicine Services and Medication Treatment:
1. Medication Treatment Consent (Semaglutide/Tirzepatide):
- I understand that I have the right to decline or discontinue treatment at any time and will notify my doctor before doing so.
- I assume responsibility for taking my medication and waive any liability from RenewMe Wellness LLC, Dr. Memon, or any other affiliated provider.
- I have sought the medical services of RenewMe Wellness LLC due to my excess weight or obesity. I have discussed the limited success I have had in losing weight through dieting and exercise alone.
- I understand I will be prescribed medications, including Semaglutide or Tirzepatide.
- I understand that I will need to change my diet, exercise frequency, and behaviors to aid in my long-term weight reduction efforts. I acknowledge that the management of my weight will require lifelong effort, regardless of the method of weight reduction. No drug can provide a quick fix for weight reduction and management.
2. Disclosure of Medical Conditions:
- I have fully disclosed any medical conditions or diseases that may impact my treatment, including but not limited to:
  Pregnancy or attempts to become pregnant
  Breastfeeding
  Gallbladder disease, diabetes, autoimmune diseases, HIV, heart disease, liver disease, kidney disease
  Uncontrolled high blood pressure, seizure disorders, blood disorders, anemia, thalassemia, hemophilia
  Emphysema, asthma, history of stroke or cancer, multiple endocrine neoplasia Type II, or medullary thyroid carcinoma
- I understand that if I fail to disclose any medical conditions, I release RenewMe Wellness LLC, Dr. Memon, and affiliated providers from any liability associated with my treatment.
3. Understanding of Medication Risks:
- I acknowledge that Semaglutide is 94% similar to natural human glucagon-like peptide 1 (GLP-1), and Tirzepatide is the first dual GIP/GLP-1 receptor co-agonist. Both medications regulate appetite and reduce food intake by decreasing hunger and increasing feelings of fullness.
- For long-term success, I understand that the treatment must be combined with lifestyle changes, including nutritional, exercise, and behavioral habits.
- I understand that the use of Semaglutide/Tirzepatide may expose me to risks, including but not limited to:
  Low blood sugar (glucose ≤70 mg/dL), fast heart rate, sweating, shakiness, intense hunger, confusion, nervousness, overstimulation, restlessness, dizziness, insomnia, euphoria, dysphoria, tremor, headache, dry mouth, diarrhea, constipation, other gastrointestinal disturbances, medication allergies, impotence, or changes in libido.
- I further understand that my use of Semaglutide/Tirzepatide may expose me to more serious risks, including:
  Pancreatitis, cholelithiasis (gallstones), cholecystitis (gallbladder disease), thyroid disease, changes in heart rate, and dehydration.
4. Safety and Instructions:
- I agree to take Semaglutide/Tirzepatide as prescribed by my doctor and not provide this medication to any other person.
- I will not increase my dosage or combine this medication with any other drug or substance without the recommendation of my doctor.
- I understand that improper use of these medications can lead to serious injury or death.
- If I begin experiencing unusual or unexpected symptoms after starting Semaglutide/Tirzepatide, I will seek immediate medical attention. This may include contacting another qualified physician or going to a hospital emergency room. Symptoms may include but are not limited to: shortness of breath, swelling of hands, legs, or feet (edema), rapid heart palpitations or tachycardia, nervousness, restlessness, insomnia, tremors, rapid breathing, or difficulty tolerating exercise or activity.
5. Off-Label Use Acknowledgment:
- I acknowledge that Semaglutide and/or Tirzepatide may be prescribed for off-label uses. These medications are FDA-approved for specific indications but may be recommended for other purposes.
- I have been informed of the off-label nature of these medications and accept the potential risks, including unknown long-term effects, as discussed with my physician.
6. Seeking Medical Attention:
- If I experience any unusual symptoms, such as shortness of breath, swelling, rapid heart rate, or difficulty tolerating physical activity, I will immediately seek medical help from another qualified physician or go to a hospital emergency room.
7. Medication Use Guidelines:
- I will use Semaglutide/Tirzepatide only as prescribed by my doctor.
- I will not provide this medication to anyone else.
- I understand that improper use or illegal transfer of this medication to another individual can result in serious injury or death.
8. Fees and Refund Policy:
- I understand the fees associated with the weight loss program and agree to fulfill my financial obligations.
- According to FDA Policy Sec. 460.300, I acknowledge that I cannot return or receive refunds for medications and/or injections once dispensed, regardless of effectiveness or possible adverse reactions.
9. Limited Scope of Care:
- I acknowledge that RenewMe Wellness LLC, Dr. Memon, or any affiliated provider supplements my care and does not replace my primary care provider. Responsibility for my overall healthcare should remain with my primary care provider, and I am encouraged to establish or maintain a relationship with one if I do not already have one.
10. Privacy Policy:
- By providing my email address or phone number, I consent to receive unsecured healthcare communications, including appointment reminders, at these contacts.
- I understand that standard text messaging rates or cellular phone charges may apply according to my wireless plan.
11. Telemedicine Consent:
- I authorize RenewMe Wellness LLC to provide healthcare services through telemedicine, which may involve the use of telehealth equipment and communication with providers outside of my physical presence.
- I will ensure I have access to the necessary technology for telemedicine appointments.
- I understand the risks and limitations of telemedicine and consent to its use.
- I agree to verify my identification by showing a valid ID at the beginning of my scheduled appointment.
- I will notify my provider of my location honestly and of any changes before my telehealth visit.
12. Arbitration Agreement:
- In the event a dispute arises over the outcome of this treatment, I consent solely to arbitration as a legal means of settlement.
13. Acknowledgment:
- By signing below, I confirm that I have read and understood the information on this form, and that all the information I have provided is accurate to the best of my knowledge.
- I understand that it is my responsibility to inform RenewMe Wellness LLC, Dr. Memon, or any affiliated provider of any changes to my medical history.
- This consent is ongoing and will remain in effect even after a diagnosis is made and treatment begins.
- I retain the right to discontinue services at any time and to discuss any aspect of my treatment plan with RenewMe Wellness LLC, Dr. Memon, or any affiliated provider.
- I understand that I should not sign this consent form unless I fully understand its contents, as well as the risks and benefits associated with the proposed treatment.
- I agree to release RenewMe Wellness LLC, Dr. Memon, or any affiliated provider from any liability associated with Semaglutide/Tirzepatide treatment.
Name*

First NameMiddle NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
IMPORTANT: After hitting submit, please fill out the Medication Consent form to send your prescription to the pharmacy for delivery. The link will be provided after you submit this page.
Should be Empty:

Medical History and Consent Form

Medical History Intake

Eligibility Confirmation:

Personal Information:

Weight Information:

Social History:

Family Medical History:

Medications:

Privacy Policy:

Telemedicine consent:

Acknowledgment:

Consent for Telemedicine Services and Medication Treatment: