Verity Metabolic Health, LLC

Verity Metabolic Health, LLC

Supervised Medical Weight Management Provider: Carolina Jarvis, PA-C
Please complete this form in full prior to receiving services.
Patient Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Location (City/State)
Must be in New Mexico at time of visit
Height (ft/in)
Weight (lbs)
Medical History
Do you have any of the following?

Other
Other
Have you ever had pancreatitis?
Do you have any gastrointestinal disorders?
If yes, please explain:
Current Medications
List all medications you are currently taking:
Are you currently taking any weight loss medications?
If yes, which:
CRITICAL SAFETY SCREENING
Do you have a personal or family history of Medullary thyroid cancer?
Do you have a personal or family history of MEN2 (Multiple Endocrine Neoplasia type 2)?
Pregnancy Status
Are you currently pregnant, planning pregnancy, or breastfeeding?
Weight Loss Goals
What is your primary goal?

Other
Have you tried weight loss before?
If yes, what worked or didn’t:
TELEHEALTH CONSENT
Please check to confirm:
GLP-1 MEDICATION CONSENT
Consent checkboxes
PROGRAM & MEDICATION ACKNOWLEDGMENT
Please check to confirm:
Payment Policy
I understand Verity Metabolic Health is a self-pay practice. Payment for professional services is the patient’s responsibility. Invoices are due within 7 calendar days of the invoice date, unless other arrangements have been made in advance. Any outstanding balance may be required to be paid before additional non-emergency appointments, services, or medication-related services are provided. Patients are encouraged to contact Verity Metabolic Health promptly with any questions regarding an invoice or if they need to discuss payment arrangements.
Program Cost
Comprehensive evaluation and medical management 2.5 mg, four-week supply: $235
Follow-up visit and medical management 2.5 mg, four-week supply: $190
Follow-up visit and medical management 5 mg, four-week supply: $215
Follow-up visit and medical management 7.5 mg, four-week supply: $255
Follow-up visit and medical management 10 mg, four week supply: $295
Follow-up visit and medical management 12.5 mg, four week supply: $335
Current package pricing:
Appointment Cancellation & No-Show Policy
Please check to confirm:

Verity Metabolic Health understands that unexpected circumstances may arise. If you need to cancel or reschedule your appointment, please provide at least 24 hours notice whenever possible. The first missed appointment may be waived as a one-time courtesy. Subsequent appointments that are missed or canceled with less than 24 hours’ notice may be subject to a $25 no-show/late cancellation fee. No-show and late cancellation fees are the patient’s responsibility and are not applied toward the cost of future visits or medications. Repeated missed appointments may affect the ability to schedule future appointments with Verity Metabolic Health.
Verity Metabolic Health understands that unexpected circumstances may arise. If you need to cancel or reschedule your appointment, please provide at least 24 hours’ notice whenever possible. The first missed appointment may be waived as a one-time courtesy. Subsequent appointments that are missed or canceled with less than 24 hours’ notice may be subject to a $30 no-show/late cancellation fee. No-show and late cancellation fees are the patient’s responsibility and are not applied toward the cost of future visits or medications. Repeated missed appointments may affect the ability to schedule future appointments with Verity Metabolic Health.
PRIVACY/HIPAA ACKNOWLEDGMENT
EMERGENCY AGREEMENT
Please check to confirm:
FINAL ACKNOWLEDGMENT
SIGNATURE
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Signature

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I certify that the above information is accurate and complete to the best of my knowledge
I understand that submission of this intake form does not establish a provider–patient relationship and does not guarantee eligibility for treatment or scheduling. My information will be reviewed prior to appointment approval. I agree to seek emergency care for urgent or life-threatening symptoms. Please check to confirm:
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Verity Metabolic Health, LLC

Please complete this form in full prior to receiving services.

Patient Information

Medical History

Current Medications

CRITICAL SAFETY SCREENING

Pregnancy Status

Weight Loss Goals

TELEHEALTH CONSENT

GLP-1 MEDICATION CONSENT

PROGRAM & MEDICATION ACKNOWLEDGMENT

Payment Policy

Program Cost

Appointment Cancellation & No-Show Policy

PRIVACY/HIPAA ACKNOWLEDGMENT

EMERGENCY AGREEMENT

FINAL ACKNOWLEDGMENT

SIGNATURE