Dr. V Health Intake Form

Patient status*

NEW PATIENT (first visit with our clinic)ESTABLISHED PATIENT (you have been seen by us before)

Full Name*

First NameMiddle NameLast Name

Date of birth*

Date

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email Address*

example@example.com

Reason for your visit?*

Please select how you would like to receive care. Membership plans include ongoing support and follow-ups. Pay-per-consult is available for one-time visits.*

Wellness Membership $69.99Premium Membership $79.99Pay Per Consult/Refill $99.99Already have an active membership (no changes needed)

Address

Street Address

Street Address Line 2

CityState (you must be physically located in this state at the time of your visit)

Postal / Zip Code

What is your gender?*

FemaleMale

Height (Inches)*

Current Weight (lbs)*

Please list your preferred PHARMACY:*

Rows	Pharmacy Information
Name
Address
Phone Number

Are you taking any medications?*

YesNo

Please list all medications/supplements below (name, dose and frequency)

Do you have any allergies?*

YesNo

Please list Allergies and Reaction below

Have you had any surgeries?*

YesNo

Please list all previous surgeries if any including year

Please indicate if any family members (parents, siblings, or children) have a relevant medical history:

Rows	Alive	Deceased	Relevant Medical History
Father
Mother
Siblings
Children

Do you use any kind of tobacco/vape or have you ever used them?*

YesNo

What kind of tobacco products? How long have you used/been using them?

Do you use any kind of illegal drugs or have you ever used them?*

YesNo

What kind of drugs? How long have you used/been using them?

How often do you consume alcohol?*

NeverOccasionallyRegularlyDaily

Preventive Testing

Rows	Year
Physical Exam
Eye Exam
Colonoscopy
Endoscopy
Pap Smear
Mammogram

Gynecological History

Rows	Please be specific
Last Menstrual Period
Menopause
Full Term Pregnancies
Vaginal Deliveries
C Sections
Miscarriages/abortions

CONSENT TO RELEASE HEALTH INFORMATION TO A RELATIVE:*

I do not authorize anyone else to receive my health information.I authorize the release of my health information to the person indicated below.

Please indicate name and relationship of authorized person*

To receive the following information (check all that apply):*

Billing & Membership Policy – Dr. V Health
⚠️ Important:
An active membership (Wellness or Premium) or a Pay-Per-Consult visit is required in addition to the cost of medication.

Membership or consultation fee must be selected and paid at the time of scheduling in order to receive care, prescriptions, or refills.

🔁 Membership Payment Policy
Patients enrolled in a membership are responsible for maintaining an active and valid payment method at all times.

If a membership payment fails, the patient will be notified and must update their payment method promptly to maintain active status.

After three (3) failed payment attempts (“strikes”), the membership will be automatically canceled without further notice.

Once canceled, the patient will lose all membership benefits, including follow-up visits, messaging access, and prescription refills.

Any future care, including medication refills, will require a Pay-Per-Consult or refill visit fee (currently $99).

Re-enrollment in a membership may be required and is subject to provider approval.

🛡️ Additional Policies & Disclosures

1. Telemedicine Consent
By proceeding, you acknowledge that you are requesting care via telemedicine and agree to receive services based on your reported location at the time of the visit. I consent to the use of electronic prescribing to transmit prescriptions to my pharmacy of choice. You may request access to your medical records, request corrections, and file a complaint if you believe your rights have been violated.

2. State Requirement Disclaimer:
Services are only provided to patients physically located in a state where the provider is licensed at the time of the consultation. You confirm that you are physically located in the state you selected at the time of this visit. Services are only provided to patients located in states where the provider is licensed.

3. No Guarantee of Prescription:
Payment does not guarantee that a prescription will be issued. All treatments are based on medical evaluation and provider discretion.

4. Non-Refund Policy:
All consultation and membership fees are non-refundable, including cases where treatment is not prescribed.

5. Patient Responsibility:
Patients are responsible for:

Providing accurate medical history
Completing required forms
Attending scheduled visits
Failure to do so may result in delays or inability to receive treatment.

6. Medication Fulfillment Disclaimer
Medication availability, compounding pharmacies, and shipping timelines are not controlled by Dr. V Health and may vary.

7. Communication Consent:
By submitting this form, you consent to receive communication via SMS, email, or phone regarding your care, appointments, and billing.

(text, email, video) may carry inherent privacy risks despite reasonable safeguards.

8. Dr. V Health does not provide emergency medical services.

If you are experiencing a medical emergency, call 911 or go to the nearest emergency room.

9. Peptide Disclaimer:

Some treatments, including peptide and hormone therapies, may be prescribed off-label and are not FDA-approved for all indications. All treatments are based on provider discretion.

10. HIPAA Authorization and Privacy Acknowledgment
By submitting this form, you authorize Dr. V Health to use and disclose your health information for purposes of treatment, payment, and healthcare operations, in accordance with applicable privacy laws, including HIPAA.

You understand that you may request access to your medical records, request corrections, and request restrictions on certain disclosures.

You acknowledge that a full Notice of Privacy Practices is available upon request.

This authorization remains valid for the duration of the patient-provider relationship unless revoked in writing.

I acknowledge and agree to the Membership Payment Policy, including automatic cancellation after failed payments.*

I acknowledge and agree

I acknowledge and agree to the Telemedicine Consent, Financial Policy, No-Refund Policy, No Guarantee of Prescription, and all additional disclosures listed above.*

I acknowledge and agree

Preferred Appointment Date and Time*

Dr. V Health would like your consent to send text message communications from +18333785483 to your mobile number listed above, regarding account notifications. Consent is not a condition of purchase. Message frequency varies. Message and data rates may apply. Reply 'STOP' to unsubscribe at any time. Reply 'HELP' for assistance or more information. We do not share your mobile opt-in information with anyone. See our Privacy Policy for more information on how we handle your data. Mobile opt-in information is never shared with third parties for marketing purposes.*

Yes, I consent to receive informational messages from Dr. V Health regarding account notifications.No, I do not want to receive any text messages from Dr. V Health

I confirm that I am physically located in the state listed above at the time of this visit.*

I confirm my location

I certify that the information provided is accurate.*

Date

Dr. V Health Intake Form

This secure medical intake takes approximately 5–7 minutes to complete.

Patient Authorization to Release Information