GLP1 Patient Medical History Form

First Name

Middle Name

Last Name

Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Sex

Acknowledgment of a full physical in the last year

Height (inches)

Example: 68

Weight

Driver's License State

Driver's License Number

Statement of Patient Rights and Responsibilities

Patients have the right to receive respectful, safe, and quality care without discrimination, including the right to make informed decisions about treatment, access medical records, and have an advance directive. Patients are also protected from abuse, neglect, and unauthorized restraint.

Endless Vitality Key Patient Rights

Quality Care: To receive safe, respectful, and high-quality care that supports individual needs, culture, and values.
Information and Consent: To be fully informed about diagnosis, treatment options, risks, and benefits, and to give or refuse consent.
Confidentiality: Privacy of medical records and personal information, which can only be released with permission or as required by law.
Involvement in Care: To participate in treatment decisions, including creating an Advance Directive (living will or healthcare power of attorney).
Freedom from Abuse: To be free from mental, physical, sexual, and verbal abuse, neglect, and exploitation.
Complaint Process: To voice complaints about care or treatment without fear of retaliation.
Access to Records: To review or receive a copy of your own medical records according to state law.
Pain Management: To receive appropriate assessment and management of pain.

Endless Vitality Patient Responsibilities

Providing accurate information about health history.
Following recommended treatment plans or informing staff if they choose not to.
Being respectful of staff and other patients.

Patient Initials

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

HIPAA CONSENT TO LEAVE MESSAGE

Date of Birth

Date

Email Address

example@example.com

Phone Number

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

Medical History (conditions, surgeries, chronic disease)

Current Medications (include TRT, peptides, supplements)

Allergies (please list any allergies)

Current Medical Conditions (check all that apply)

Treatment Interest

Statement of Patient Acknowledgments by Treatment Modality

TRT Risk Acknowledgment: infertility risk understood, cardiovascular risk understood, requires lab monitoring, natural testosterone suppression.

Peptide Therapy Acknowledgment: off-label use understood, limited long-term data, injection risks understood, variable outcomes acknowledged.

GLP-1 / GIP Therapy Acknowledgment: GI side effects understood, gallbladder risk understood, pancreatitis risk understood, thyroid tumor warning understood.

Financial Policy Acknowledgment

Cash-pay clinic understood, No insurance billing, No guaranteed outcomes

HIPAA & Patient Rights Acknowledgment

HIPAA notice received, Right to refuse treatment understood, Medical record access understood, Complaint rights understood

Patient Signature