Welcome to FMW Services!! Please fill out the following information thoroughly so the Provider can individualize your care. We look forward to serving you!

How would describe your mood, generally:

What types of diet and exercise approaches have worked for you in the past?

Let's get a current picture of your health

I. Procedure and Alternatives: I,___________________________ (patient or patient’s guardian) authorize The Providers of FMW MedSpa, to assist me in my weight reduction efforts. I understand my treatment may involve, but not be limited to, the use of appetite suppressants for more than 12 weeks and when indicated in higher doses than the dose indicated in the appetite suppressant labeling. 1. I have read and understand my doctor’s statements that follow: Medication, including the appetite suppressants, have labeling worked out between the makers of the medication and the Food and Drug Administration. This labeling contains, among other things, suggestions for using the medication. The appetite suppressants labeling suggestions are generally based on shorter term studies (up to 12 weeks) using the dosages indicated in the labeling. As a Provider, I have found the appetite suppressants helpful for periods far in excess of 12 weeks, and at times in larger does than those suggested in the labeling. As a Provider, I am not required to use the medication as the labeling suggest, but I do use the labeling as a source of information along with my own experience, the experience of my colleagues, recent longer term studies and recommendations of university based investigators. Based on these, I have chosen, when indicated, to use the appetite suppressants for longer periods of time and at times, in increased doses. Such usage has not been as systematically studied as that suggested in the labeling and it is possible, as with most other medications, that there could be serious side effects (as noted below). As a Provider, I believe the probability of such side effects is outweighed by the benefit of the appetite suppressant use for longer periods of ti

III. Risk Associated with Being Overweight or Obese: I am aware the there are certain risk associated with remaining overweight or obese. Among them are tendencies to high blood pressure, to diabetes, to heart attack and heart disease, and no arthritis of the joints, hips, knees and feet. I understand these risks may be modest if I am not very much overweight but that these risks can go up significantly the more overweight I am. IV. No Guarantees: I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I also understand that I will have to continue watching my weight all my life if I am to be successful. V. Patient’s Consent: I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained, or any questions I have concerning them have not been answered to my complete satisfaction. I have been urged to take all the time I need in reading and understanding this form and in talking with my doctor regarding risks associated with the proposed treatment and regarding other treatments not involving the appetite suppressants.

WARNING: IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THE PROPOSED TREATMENT, OR ANY QUESTION WHATSOEVER CONCERNING THE PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK YOUR PROVIDER NOW BEFORE SIGNING THIS CONSENT FORM.

FINANCIAL POLICY

Thank you for selecting FMW Services for your health care needs. We are honored to be of service to you and your family. This is to inform you of our billing requirements and our financial policy. Please be advised that payment for all services will be due at the time services are rendered. For your convenience, we accept Cash, Visa, MasterCard and American Express.

 

I agree that should this account be referred to an agency or an attorney for collection, I will be responsible for all collection costs, attorney’s fees and court costs.

 

I have read and understand all of the above and have agreed to these statements.

 

I have read the following documents (are in the pdf version of this intake), fully understand them and agree to their terms (please sign with your cursor below). Documents: Rules & Responsibilities, Acknowledgement and Consent to Privacy Practices and Consent to Limited Treatment