Gut Guru Medical Consent and Indemnity Form

  • Mapo Wellness Center, LLC New Patient Information and Consent Form

    Mapo Wellness Center, LLC practices in a Non-Judgmental and Confidential Manner with all Patients. This form is not an attempt to provide specific medical advice, and it should not be used to make a diagnosis or to replace or overrule a qualified health care provider's judgment. Always seek the advice of your physician or other qualified health care provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care regimen, and never disregard professional medical advice or delay in seeking it because of something you have read on this website.
  • Format: 0000 000 000.
  • Date of Birth*
     - -

  • Patient History

  • Do you take regular medication?*
  • Do you have any pre-existing Health Conditions Mapo Wellness Center should be aware of?*
  • Do you suffer from any thyroid conditions?*
  • Do you have any known allergies to Medications or Foods?*

  • Lifestyle

  • Do you believe your diet supports your Health?*
  • How often do you exercise?*
  • Do you Smoke Tobacco?*
  • Do you drink Alcohol?*
  • Do you drink Caffeine?*

  • Outcomes

  • Consent

    Please answer the following questions regarding consent
  • Consent to Mapo Wellness Center obtaining labs and lab results*
  • Consent to Mapo Wellness Center administering GLP-1injections directly or indirectly*
  • Consent to Mapo Wellness Center for being contacted via telephone, email, or telehealth*
  • Should be Empty: