Weight Loss Intake Form

Weight Loss Intake Form
Patient Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Marital Status*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
example@example.com
Current Occupation
Employer
Emergency Contact Information
Name

First NameLast Name
Relationship to you
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Pharmacy Information
Pharmacy
Phone
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE AND FINANCIAL POLICY
I acknowledge that I have received a copy of RevitaLife's Privacy Notice and Financial Policy.
Signature of Patient or Guardian*

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Date*

MonthDayYear
Date
Patient History
Height
Weight History
Highest
Lowest
Current
Why do you want to lose weight?
What weight loss approaches have been tried in the past and which were successful?
What weight loss approaches have been tried in the past and which were successful?

Eat 3 meals a dayFrequent snackerBinge eaterConstant dieterEat more than 3 meals a dayHealthy eaterEmotional/stress eaterConvenienceOther
How much water do you drink?
How often do you consume caffeine?
How often do you eat out?
Food allergies?
Food sensitivities?
Food cravings?
Food dislikes?
13354 Manchester Rd, Ste. 100, St. Louis, Mo 63131 | 314-475-3126
Typical breakfast
What
When
Typical lunch
What
When
Typical dinner
What
When
Please answer the following to determine possible underlying health issues that could be affecting your weight loss
How would you rate your overall sleep?

GreatFairPoor
How many hours of sleep do you get?
How would you rate your overall energy levels?

GreatFairPoor
How would you rate your stress level?

HighModerateLow
What are your sources of stress?
What do you do to manage your stress level?
Do you eat because of stress/emotions (explain)?
Have you ever done anything to detox?

YesNo
Explain
How often do you exercise?
What exercise/movement activities do you enjoy?
Medical History

Medical Conditions: Please list all medical conditions you have or had in the past.

	Medical Conditions
1
2
3
4
5
6

Medication: Please list current prescription medications you take & why

	Medication	Dose	Frequency	Reason for Use
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Herbal/Supplement: Please list any supplements you take regularly & why

	Herbal/Supplement	Reason for Use
1
2
3
4
5
6
7
8
9
10

Signature*

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Date Signed*

MonthDayYear
Date
Patient Consent to Treatment
By reading and signing this document the undersigned patient (or authorized representative) consent to, agree and authorize RevitaLife to perform treatments, examinations, prescribe medications, medical services and diagnostic procedures as ordered and approved by the physician and RevitaLife staff and discussed with me. I understand that I may have other conditions that will continue to be cared for by my primary care physician. I acknowledge and consent to the following:
1. I am at least 18 years of age and I have provided a full and accurate medical history to RevitaLife. I acknowledge that the medical history I provided to RevitaLife is true and accurate and I am aware that any Information I did not provide prior to treatment cannot hold RevitaLife personnel treating me responsible for loss or liability that may result due to my failure to provide such information.
2. I understand and agree that as a condition to my receiving treatment with RevitaLife I will continue to visit my primary care physician, regardless of the extensive follow ups specific to the diagnosis discussed by my RevitaLife physician or treating personnel.
3. RevitaLife physician, personnel, and healthcare professionals cannot guarantee any specific results of any examination, treatment, procedure, or medical care. I release RevitaLife, its providers, and healthcare professionals from any and all liability for any accident or injury that is not directly caused by the negligence of RevitaLife or its employees. I further understand that the overall diagnosis and treatment may involve risks or injuries. As a result, I understand and agree to hold RevitaLife personnel and RevitaLife physicians harmless and free of liability if I should encounter an adverse event related to the treatment or medications prescribed that could result in my incurring additional medical costs.
4. During the course of my care and treatment, I understand that various types of examinations, tests, and diagnostic or treatment procedures may be necessary. These procedures may be performed by physicians, nurses, technicians, or other healthcare professionals. While routinely performed without incident, there may be material risks associated with these procedures; I will ask my healthcare professional or physician to provide me with additional information. I understand RevitaLife personnel and or physicians may ask me to sign additional informed consent documents relating to specific procedures and treatments.
5. I agree not to give, sell, or allow anyone other than myself to use any medication provided to me through my treatment with RevitaLife.
6. I understand that RevitaLife has contracts with pharmacies for compound medications.
7. I understand that hormones and the ancillary use of medications while taking hormones or undergoing treatment for a specific diagnosis observed by a RevitaLife physician can result in the unknown side effects which may not become evident until a future date. As a result, I agree to take my medications exactly in the manner prescribed to me by my RevitaLife physician and agree to release RevitaLife, or RevitaLife personnel and RevitaLife physicians from any liability for any misuse, unintended use, or unauthorized use of the medication prescribed.
8. If the medications prescribed may be injected and I chose to inject myself, I agree to hold harmless RevitaLife, RevitaLife personnel and /or RevitaLife physicians if the same results in injury or harm to myself. I understand that RevitaLife and /or its affiliates will provide as much information and Instruction as possible to assist in minimizing harm to myself.
9. I authorize and agree to allow RevitaLife to utilize my lab results, observations and or outcomes of my treatment in future studies which will not disclose my demographic information.
10. I understand that RevitaLife physicians may have elected to opt out of medical malpractice insurance due to the unique and unconventional nature of the medical treatment, and I cannot hold them responsible and will not attempt to hold them responsible for the diagnosis and treatment, risks, potential harm or injuries or outcomes that may result from initiation or continuation of therapy indefinitely.
11. I understand that RevitaLife professionals involved in my care will rely on my documented medical history, as well as other information provided by me, my immediate family, or others having information about me, in determining whether to perform or recommend certain procedures or treatment. Throughout the course of my treatment I agree to provide accurate, updated and thorough information regarding my medical history and any conditions or events, which may impact medical decision making.
By signing this document, I certify that I have read and understand its contents and the information provided by me is accurate and complete.
Patient’s Signature*

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Patient’s Printed Name*
Date*

MonthDayYear
Date
Optional: I hereby authorize RevitaLife to use any of my comments as testimonials for future marketing and advertising.
Initials
RevitaLife Advanced Beneficiary Notice (ABN)
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
This notice is to inform you that your insurance company may not pay for all of the services that you receive in the course of your treatment at our clinic. This may include, but is not limited to:
- Genova Testing
- Additional Blood Testing
- Pellets
- Injections
- Medical Weight Loss Programs
- Food
- B12 Medication
- Cosmetic Services
- Supplements
- Skin Care
- Office Visits
- EKG
- IV Nutrition
Each insurance’s out of network benefits are unique as to what services you could be reimbursed for. Treatments that are not reimbursable by any insurance to you will be your full responsibility at the time of service. By signing this notice, you agree to take financial responsibility for the costs of supplies or services provides.
Patient Signature *

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Date Signed*

MonthDayYear
Date
Consent to Use Artificial Intelligence During Encounters
We are committed to providing the best possible care for you, and as part of this commitment, we are continually looking for ways to enhance our services.

We would like to inform you about a new technology that we are using called Freed. Freed is an artificial intelligence (AI) tool that assists us during patient encounters by generating clinical notes based on our conversations. This tool allows us to focus more on you, the patient, and less on computer documentation. The AI tool does not interact with you directly. It merely listens to the conversation and creates a summary.

Freed is a tool that listens to the conversation during the consultation and generates a written summary or “note” based on that conversation. This note is then reviewed and approved by your practitioner.

We want to assure you that your privacy is our utmost priority. The AI tool adheres strictly to Health Insurance Portability and Accountability Act (HIPPA) compliance guidelines to endure your data is secured and protected. Only the healthcare professionals involved in your care will have access to these notes.

Your participation is completely voluntary. If you agree to use the AI scribe during your consultation please sign and date the form below. If you have any questions, please feel free to discuss them with us
I, First Name Last Name consent to the use of Freed during my medical encounters/appointments.
Patient’s Signature*

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Date*

MonthDayYear
Date
Parent/Guardian Signature (if under 18)

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Date

MonthDayYear
Date
Should be Empty:

Weight Loss Intake Form

Patient Information

Emergency Contact Information

Pharmacy Information

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE AND FINANCIAL POLICY

Patient History

Weight History

Typical breakfast

Typical lunch

Typical dinner

Please answer the following to determine possible underlying health issues that could be affecting your weight loss

Medical History

Patient Consent to Treatment

RevitaLife Advanced Beneficiary Notice (ABN)

Consent to Use Artificial Intelligence During Encounters