• Date*
     - -
  • Returning patient*
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Has your address changed since last visit?*
  • Do you have any allergies?*
  • Injections administered*
  • Are you pregnant or breastfeeding?*
  • Have you had any changes since your last visit?*
  • Are you under the care of a primary care physician?
  • Rows

  • SIGNATURE PAGE

  • Consent for treatment

    I understand that I am receiving an intramuscular or intravenous injection as a part of a wellness treatment. These injections may include a combination of vitamins, amino acids, antioxidants, or supportive nutrients. I have been informed of the potential benefits including improved energy, metabolism, immune support, and beauty enhancement. I understand that the side effects are rare but may include injection site discomfort, allergic reaction, or dizziness. I understand this treatment is elective and I consent to proceed under the supervision of a licensed medical provider. 

    HIPAA Authorization and Acknowledgement for Open Setting Communication

    As a concierge medical spa operating in a home-based setting, we strive to provide a welcoming and comfortable atmosphere. Due to the nature of our space, some discussions regarding health, wellness, and treatment goals may occur in a shared or open area where others may be present. 

    To comply with the health insurance portability and accountability act of 1996 (HIPAA), and to respect you right to privacy, we ask you to review and acknowledge the following:

    Acknowledgement of an open setting environment

    I understand that:

    - Consultations or conversations regarding weight goals, health history, treatment plans, vitamin injections, prescription therapies, IV therapy, toxin , and dermal filler may take place in an open area. 

    - Although reasonable efforts will be made to maintain confidentiality, there is a possibility that other clients or individuals may overhear portions of these conversations.

    - I am not required to have any personal health discussions in an open setting. 

    Client Rights

    - I understand that I may change my preference at any time by informing a staff member. 

    - I understand that my choice will not affect my care or access to services in any way. 

  • Payment Method*
  • Date
     - -

  • PLEASE DO NOT SUBMIT FORM AND HAND TABLET BACK TO STAFF. 

    PROVIDER ONLY DOCUMENTATION BELOW

  • Area of injection*
  • Complications?*

  • Patient presents to establish care for medically supervised weight management. Reports difficulty achieving and maintaining weight loss despite previous attempts with diet modification, exercise, and lifestyle changes. States excess weight has negatively affected overall health and quality of life. Patient is motivated to improve weight, overall wellness, and reduce obesity-related health risks. Weight history, current medications, allergies, past medical history, family history, and lifestyle habits reviewed. Risks, benefits, alternatives, potential side effects, and expectations of GLP-1 therapy discussed. Patient verbalizes understanding and wishes to proceed if medically appropriate. Baseline labs and individualized treatment plan reviewed as indicated.

    Review of Systems (ROS):

    Constitutional: Reports difficulty with weight management. Denies fever, chills, or unexplained weight loss.
    HEENT: Denies headache, vision changes, or difficulty swallowing.
    Cardiovascular: Denies chest pain, palpitations, or edema.
    Respiratory: Denies cough or shortness of breath.
    Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, constipation, or blood in stool.
    Genitourinary: Denies dysuria or urinary complaints.
    Musculoskeletal: Denies acute joint swelling or muscle weakness.
    Neurologic: Denies dizziness, syncope, numbness, or focal weakness.
    Psychiatric: Denies depression, anxiety, suicidal ideation, or homicidal ideation.
    Endocrine: Reports difficulty losing weight. Denies heat/cold intolerance or excessive thirst.
    Skin: Denies rash or concerning skin lesions.
    Physical Examination:

    General: Alert, oriented ×3, well-developed, well-nourished, in no acute distress.
    Vital Signs: Reviewed and documented.
    HEENT: Normocephalic, atraumatic. Pupils equal, round, reactive to light. Mucous membranes moist.
    Neck: Supple without thyromegaly or lymphadenopathy.
    Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops.
    Respiratory: Lungs clear to auscultation bilaterally. No respiratory distress.
    Abdomen: Soft, non-tender, non-distended. Bowel sounds present.
    Extremities: No cyanosis or edema.
    Musculoskeletal: Normal gait. Full range of motion.
    Neurologic: Cranial nerves II-XII grossly intact. No focal neurologic deficits.
    Skin: Warm, dry, intact. No rashes noted.
    Psychiatric: Appropriate mood and affect. Normal judgment and insight.

  • Should be Empty: