Cloud Med Telehealth Intake & Consent Form
Welcome! Thank you for choosing Cloud Med Anti-Aging & Regenerative Institute.This Telehealth Intake Form helps our medical team understand your health history, goals, and eligibility for services. All information is confidential and protected under HIPAA.Please complete this form fully and honestly. Incomplete or inaccurate information may delay your consultation.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Appointment
Telehealth Acknowledgment Telehealth allows you to receive medical services remotely through secure audio and/or video communication. By proceeding, you acknowledge that: Telehealth is not a replacement for emergency or in-person care when medically necessary There are potential limitations to diagnosis without a physical examination You may be advised to seek in-person care if clinically appropriate. Do you consent to receive telehealth services?
*
Yes
No
Medical HistoryPlease check all that apply:
High blood pressure
Diabetes / Prediabetes
Thyroid disorder
Heart disease
Autoimmune condition
Anxiety or depression
Hormonal imbalance
Kidney disease
Liver disease
None of the above
Current Medications & SupplementsList all prescription medications, over-the-counter medications, vitamins, supplements, or injections you are currently taking.
How would you rate your current level of engagement with wellness activities?
*
Not engaged
1
2
3
4
Very engaged
5
1 is Not engaged, 5 is Very engaged
Allergies
No known allergies
Yes (please list):
Weight-Loss & Metabolic Health (If Applicable)Have you ever used weight-loss medications or peptides before?
Yes
No
How did you hear about this Virtual Wellness Orientation?
*
Please Select
Email invitation
Social media
Friend or colleague
Organization announcement
Other
Treatment InterestsPlease select all services you are interested in discussing:
GLP-1 Medical Weight Loss
Peptide Therapy
Anti-Aging & Longevity Optimization
Hormone Support
Immune Support
IV Therapy
Oxygen Therapy
Other (please specify)
Is there anything else you would like us to know before the orientation?
HIPAA & Privacy Acknowledgment I understand that my health information will be used solely for treatment, payment, and healthcare operations in accordance with HIPAA regulations. Signature (Please sign below to confirm your registration and agreement)
*
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