Weight loss Screening and Consent

Weight loss Screening and Consent

Please complete this form to provide your information, medical history, and consent for weight management therapy.
Section 1: Patient Information

Please provide your personal and contact details.
Full Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Biological Sex*

MaleFemaleIntersexOther
Mobile Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
By providing your phone number, you agree to receive text messages from Harbor Health & Wellness. Message & data rates may apply. You can reply STOP to opt-out.
Email Address*
example@example.com
Shipping Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Section 2: Medical History

Please check all that apply and provide medication/allergy information.
Section 7: Physical Measurements

Please provide your height, current weight, and goal weight.
Height (inches)*
Current Weight (lbs)*
Goal Weight (lbs)*
Section 8: GLP Medication History

Please answer the following question about GLP medication usage.
Have you taken GLP medication before?*

YesNo
Check all that apply:*

Personal or Family History of Medullary Thyroid Cancer (MTC)Personal or Family History of Multiple Endocrine Neoplasia (MEN 2)History of PancreatitisHistory of Gallbladder Disease or StonesHistory of Gastroparesis or GI ObstructionsHistory of Type 1 Diabetes or Diabetic RetinopathyCurrently Pregnant, Breastfeeding, or Planning PregnancyNONE OF THE ABOVE APPLY TO ME
Medical History
Medical History / Diagnosis*
List Current Medications*
List Known Drug Allergies*
Section 3: Informed Consent & Disclosures

Read the following disclosures carefully.
I hereby consent to undergo weight management therapy using GLP-1 or GLP-3 medications. I understand that these medications may be prescribed "off-label" or may be compounded versions of existing medications. I am specifically aware that GLP-3 (Triple Agonists) may be investigational and have not been specifically FDA-approved for the treatment of obesity in all forms. I voluntarily assume the risks of treatment, which include gastrointestinal distress, pancreatitis, and gallbladder disease. I acknowledge the theoretical risk of thyroid C-cell tumors found in animal studies and agree to report any neck lumps, hoarseness, or severe abdominal pain to my provider immediately.
Section 4: Practice & Financial Policies

Review the practice and financial policies below.
I acknowledge that Harbor Health and Wellness is an independent practice and that my provider is a Nurse Practitioner licensed in Kansas. I understand and agree that no medication will be ordered or transmitted until my Stripe invoice has been paid in full. I acknowledge that consultation fees cover professional time and evaluation and are non-refundable. I further understand that medical results vary by individual and no specific weight loss outcome is guaranteed.
Section 5: HIPAA & Telehealth

Review HIPAA and telehealth disclosures below.
I consent to receive medical treatment via telehealth and acknowledge that electronic transmissions are not 100% secure. I acknowledge receipt of the HIPAA Notice of Privacy Practices. I authorize Harbor Health and Wellness to communicate with me via SMS and Email for the purposes of billing links, scheduling, and general practice updates, acknowledging that these channels are not encrypted for clinical data.
Section 6: Attestation & Signature

Please review the attestation and sign below.
I certify that the medical history provided above is true and accurate to the best of my knowledge. I have had the opportunity to ask questions regarding my treatment plan and have had them answered to my satisfaction. I voluntarily assume all risks associated with this medical therapy.
Patient Signature*
Date*

MonthDayYear
Date
Should be Empty:

Weight loss Screening and Consent

Section 1: Patient Information

Section 2: Medical History

Section 7: Physical Measurements

Section 8: GLP Medication History

Medical History

Section 3: Informed Consent & Disclosures

Section 4: Practice & Financial Policies

Section 5: HIPAA & Telehealth

Section 6: Attestation & Signature