Patient Admission and Consent Form

Patient Admission and Consent Form

SLIMCARE MEDICAL WEIGHT LOSS AND WELLNESS CLINIC
Patient Information

HIPAA Compliant Form
Patient Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Height Ft Inch*
Weight lbs*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Emergency Contact
Emergency Contact Name

First NameLast Name
Relationship to Patient
Emergency Contact Number
Please enter a valid phone number.
How did you hear about us?*
Name of friend or entity
Medical History
Please select any relevant condition below:*

Adrenal disorderDiabetesRetinopathyKidney disorder/diseaseAngioedemaEating disorder historyLiver disorderAnemia/Blood disorderEpilepsy/SeizuresMental health problemsAsthmaGastric/Duodenum ulcerNeurological disorderAutoimmune conditionHeart diseasePancreatitisBlood clotting disorderHigh blood pressureParathyroid disorderCancer/History of cancerHigh blood cholesterolPhlebitisCholelithiasisHIV/AIDS or HepatitisRenal failureDeep vein thrombosisIBD/IBSSubstance abuseDepression/Suicidal ideationInfective endocarditisThyroid diseaseNone of the aboveOther
Details or any other conditions:
Have you or a family member been diagnosed with either of the following?*

Multiple Endocrine Neoplasia Syndrome Type 2 (MEN2)Medullary Thyroid CarcinomaNone of the above
If yes, please explain:
Note: GLP-1 agonist medications

(e.g., Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy®)
Are you allergic to any of the following?*

B VitaminsGLP-1 Receptor AgonistsAdhesives/latexBenzyl AlcoholL-CarnitineNone of the aboveOther
Do you have any other allergies?
Are you currently taking any blood thinning drugs? (i.e., Aspirin and Warfarin)*

YesNo
If yes, please list them:
Have you had surgery in the past year?*

YesNo
If yes, please list them:
Female Medical History
Are you currently:

PregnantTrying to conceiveBreastfeedingPost-menopause
Using contraceptives, please list:

Please provide a list of all medications or supplements you take:

	Medication/Supplement	Dose	Frequency	Comments
1
2
3
4

HEALTH HABITS
Do you smoke?*

YesNo
Do you drink alcohol on a regular basis?*

YesNo
If Yes, how many weekly units?
How is your activity level?*

SedentaryLightly activeModerately activeVery active
What methods or interventions have you used to lose weight previously?*

DietExercisePrescription medicationTherapyHerbal supplementsNone of the above
Approximate Date of Last Physical*

MonthDayYear
Date
Approximate Date of Last Blood work*

MonthDayYear
Date
Relevant results i.e. A1C, Cholesterol Levels, Blood Pressure, Liver Functions :*
None if N/A
What are your main motivations and concerns for wanting to lose weight with Semaglutide?*
None if N/A
What factors do you consider contribute to your experience of excess weight?*

AlcoholLow energySedentary lifestyleExcess caloriesMedical conditionSleep disruptionsFamily historyPregnancyStress/busy lifestyleHormonal changesPerimenopauseNone of the above
Other:

Client Record Measurements: May be done at clinic or your home.

	Current Stats
Neck
Chest
Arm
Navel
Hip
Thigh
Ulna

Vital signs: May be done at clinic or your home.

	Vitals
Height
Weight
BMI
BP
Heart Rate

Upload your lab results here in the last 90 days if you want to share it with our medical team.

accepted files: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, jpg, jpeg, png
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Consent for Treatment
Patient or Legal Guardian Signature:

I, the undersigned, have read and understood the information provided on this form. I willingly consent to the following specified medical treatments and procedures.
Medical Treatment Authorization: I authorize the medical team to administer necessary medical treatments, procedures, and medications deemed necessary for my care.

Emergency Procedures: In the event of a medical emergency, I authorize the medical team to perform necessary emergency procedures and interventions.

Release of Information: I authorize the release of my medical information to my insurance provider and other healthcare providers involved in my care.
Initials*
B12 Injections Informed Consent

Vitamin B-12 helps maintain optimal health and has been shown to be beneficial in helping to reduce fatigue, improve memory, and maintain a healthy body weight. It is what your body uses to help create energy, which is one of the reasons people feel more energized when they take B12.

All medications and supplements have potential side effects, including B12. Most people tolerate B12 without issue, side effects are rare. Potential common B12 side effects include but are not limited to: mild diarrhea, upset stomach, nausea, pain at the injection site, swelling, headache and joint pain.

You acknowledge:

1. That if I begin to have side effects, I will contact SLIMCARE SAN ANTONIO MEDICAL WEIGHT LOSS CLINIC immediately and notify them of what is happening.

2. I understand that although rare, vitamin B12 injections can result in serious side effects. If these occur, you should follow up with a medical provider or go to the emergency department immediately. Uncommon and dangerous side effects include rapid heartbeat, chest pain, flushed face, muscle cramps, weakness, difficulty breathing and swallowing, dizziness, confusion, rapid weight gain, feeling of tightness in the chest, hives and rashes, shortness of breath when there is no physical exertion and unusual wheezing and coughing.

3. Before starting vitamin B12 injections I agree to make SLIMCARE SAN ANTONIO WEIGHT LOSS AND MEDICAL CLINIC to be aware if I have any of these conditions: Leber’s Disease, liver disease, kidney disease, iron deficiency, folic acid deficiency, receiving any treatment or taking any medication that has an effect on bone marrow, or drug/supplement allergies.

4. I understand that there could be interactions with B12 and certain medications/supplements.

5. The use of B12 on a weekly basis without a documented B12 deficiency is considered off label use and has not been FDA approved for increasing energy levels and weight loss.

6. Caution is advised while taking B12 if you have a sulfa allergy.

By signing below, I acknowledge that I have read the informed consent and agree to the treatment with its associated risks. I hereby give consent for B12 injections. I agree to inform my medical provider immediately if I have any side effects. I hereby release SLIMCARE SAN ANTONIO WEIGHT LOSS AND MEDICAL CLINIC, and the person injecting the B12 of any damages or liability if anything was to occur.
Initials*
SEMAGLUTIDE INJECTIONS INFORMED CONSENT

I give my consent to taking Semaglutide Injections as prescribed by my healthcare provider. Semaglutide is a human-based glucagon-like peptide-1 receptor agonist used to manage chronic weight and diabetes. I have been informed of the correct method of administering semaglutide injections and the dosage. I will not take this medication if I have a history of the following:

* Pregnant or planning to conceive while using this medication
* Personal or family history of Medullary Thyroid Carcinoma (Thyroid Cancer)
* Multiple Endocrine Neoplasia Syndrome Type 2 (MEN2).
* History of pancreatitis, kidney failure/disease, liver failure/disease, or digestive issues.
* Allergic to Semaglutide or other GLP-1 agonist medications (e.g., Adlyxin®, Byetta®, Bydureon®,
Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy®), or you have other undisclosed allergies.
* Diabetic, have retinopathy or take medication to lower blood sugar without consulting your
endocrinologist.

Possible side effects: nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dyspepsia, dizziness, abdominal distension, belching, hypoglycemia, flatulence, gastroenteritis, and gastroesophageal reflux disease. Common injection site reactions include itching, burning, and skin thickening (welting). In case of any serious allergic reaction, such as rash, itching, swelling of the face, tongue, or throat and anaphylaxis, seek immediate medical assistance.

Possible drug interactions: anti-diabetic agents, particularly Insulin and Sulfonylureas, can lead to an increased risk of hypoglycemia (low blood sugar). Additionally, do not combine with other GLP-1 agonist medicines (i.e., Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy®). Inform your provider of any medications that may lower blood sugar.

I acknowledge that semaglutide is one part of a comprehensive lifestyle approach that includes a healthy diet and exercise, and regular follow-up visits to adjust dosages are necessary.

I acknowledge that I have provided complete and accurate information and understand that it will be used to assess my suitability for any treatment. I understand that it is my responsibility to inform the therapist of any changes to my medical history or skincare routine.

By signing below, I confirm that I have been fully informed of the potential risks, benefits, and complications and I voluntarily agree to taking this medication. I have had the opportunity to ask questions, and all my concerns have been addressed to my satisfaction. I release SLIMCARE SAN ANTONIO MEDICAL WEIGHT LOSS AND WELLNESS from any liability or claims arising from the treatment.
I agree to indemnify, defend, protect, and hold harmless the medical providers employed by SLIMCARE SAN ANTONIO MEDICAL WEIGHT LOSS AND WELLNESS CLINIC; and their respective officers, directors, employees, stockholders, assigns, successors and affiliates (Indemnified Parties) from, against and in respect of all liabilities, losses, claims, damages, judgements, settlement payments, deficiencies, penalties, fines, interest and costs, expenses suffered, sustained, incurred or paid by the indemnified parties, in connection with, results from or arising out of, directly or indirectly, the medical providers employed by SLIMCARE SAN ANTONIO MEDICAL WEIGHT LOSS AND WELLNESS CLINIC; rendering medical care, services, advice, and/or treatment, my failure to disclose all relevant information regarding my medical and physical condition, acts or omissions, the medical providers employed by SLIMCARE SAN ANTONIO MEDICAL WEIGHT LOSS AND WELLNESS CLINIC; harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by the medical providers employed by SLIMCARE SAN ANTONIO MEDICAL WEIGHT LOSS AND WELLNESS CLINIC, I am aware of the potential side effects associated with semaglutide GLP1 injection provided by SLIMCARE SAN ANTONIO MEDICAL WEIGHT LOSS AND WELLNESS CLINIC, accept all the risks involved and will not seek indemnification or damages from the indemnified parties.
Patient Signature

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Patient Admission and Consent Form

Patient Information

Emergency Contact

Medical History

Note: GLP-1 agonist medications

Female Medical History

HEALTH HABITS

Consent for Treatment