Patient Intake Form for Medical History and Consent

Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
Gender*

MaleFemaleOther
Height (feet)*
Weight (lbs)*
Patient Intake Form for Medical History and Consent

Please complete this form accurately to help us provide the best care. All information is confidential and protected under HIPAA. Sections are organized for clarity and ease of use on mobile devices. Your privacy is our priority.
Have you previously been prescribed weight loss medication?*

Yes, with specificationNo
Do you have a personal or family history of Thyroid Cancer?*

SelfFamilyNone
Do you have a personal or family history of Multiple Neoplasia (Type 1 or 2)?*

SelfFamilyNone
Do you have a personal or family history of Pancreatitis?*

SelfFamilyNone
Have you experienced small bowel obstruction?*

YesNo
Do you have a history of Gastroparesis?*

YesNo
Are you currently pregnant or planning pregnancy?*

YesNo
Please list your current prescribed medications.
Do you have allergies to medication or food?*

Yes, with specificationNo
Upload a clear copy of your driver’s license (images or PDFs). Ensure the document is legible and complete.*

Cancelof
Signature

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Patient Consent for Treatment

I hereby give my consent for medical treatment as deemed necessary by my healthcare provider. I understand the nature of the treatment and the potential risks involved. Please read carefully before consenting.
I acknowledge and consent to the treatment described above.*

Yes
HIPAA Privacy Notice and Consent

I have received and reviewed the HIPAA Privacy Notice. I understand how my medical information may be used and disclosed as described in the notice. Please review carefully.
I acknowledge and consent to the HIPAA Privacy Notice.*

Yes
Authorization to Release Medical Information

I authorize the release of my medical information to third parties as necessary for my treatment, payment, or healthcare operations.
I authorize the release of my medical information as described above.*

Yes
Telehealth Consent (if applicable)

I consent to the use of telehealth services for my healthcare. I understand the risks and benefits associated with telehealth.
I consent to telehealth services.

Yes

Patient Intake Form for Medical History and Consent

Patient Consent for Treatment

HIPAA Privacy Notice and Consent

Authorization to Release Medical Information

Telehealth Consent (if applicable)