• Wellness Center of Oneonta Patient Intake Form

    Complete this secure form to begin your weight loss or wellness program.
  • Questions Before You Begin?

    If you have questions about our program, medications, pricing, or whether treatment is right for you, please call us at (205) 353-9193 before completing this medical intake form. Our team is happy to answer your questions and help you determine if you're ready to begin the medical evaluation process.

  • "What Happens Next?"

    Getting Started Is Easy

    1. Complete this form.
    2. Our provider will review your information.
    3. A licensed provider will review your medical information. Your evaluation may be completed by phone consultation, video when needed, or asynchronous chart review, depending on clinical appropriateness.
    4. If the provider determines that treatment is medically appropriate, our team will contact you regarding consultation fees, treatment options, and next steps.
    5. If medication is prescribed, the prescription will be sent for dispensing/fulfillment through an appropriately licensed pharmacy. Medication charges will not be incurred without your approval.

  • Birthday*
     - -
  • Format: (000) 000-0000.
  • May we text you regarding your treatment, payment link, and follow-up communication?*
  • Are you currently pregnant, breastfeeding, trying to become pregnant, or planning a pregnancy? IMPORTANT: If you answer Yes, please do not continue with a request for weight-loss medication until our office/provider reviews your situation. Weight-loss treatment with semaglutide or tirzepatide is not appropriate during pregnancy. Medication-specific guidance will be discussed if you are planning pregnancy.*
  • PAST MEDICAL HISTORY - Select all that apply:*
  • Family History*
  • Past Surgical History*
  • IMPORTANT GLP-1 SAFETY HISTORY - Select all that apply:*
  • Exercise Level*
  • Are you currently taking a GLP-1 medication?*
  • What services are you interested in discussing with a provider?*
  • What are your primary health goals? (Select all that apply)*
  • How did you hear about us?*
  • The Wellness Center of Oneonta LLC.,

    301 2ND AVE W ONEONTA, AL 35121

    Ph: (205)353-9193

    NOTICE OF PRIVACY PRACTICES

    THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

    I. MY PLEDGE REGARDING HEALTH INFORMATION:

    I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

    Make sure that protected health information (“PHI”) that identifies you is kept private.
    Give you this notice of my legal duties and privacy practices with respect to health information.
    Follow the terms of the notice that is currently in effect.
    I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.
    II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

    The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

    For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a health care provider were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the health care provider in diagnosis and treatment of your condition.

    Disclosures for treatment purposes are not limited to the minimum necessary standard. Because other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

    Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

    III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
    Marketing Purposes. As a health care provider, I will not use or disclose your PHI for marketing purposes.
    Sale of PHI. As a health care provider, I will not sell your PHI in the regular course of my business.
    IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.

    Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

    When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
    For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
    For health oversight activities, including audits and investigations.
    For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
    For law enforcement purposes, including reporting crimes occurring on my premises.
    To coroners or medical examiners, when such individuals are performing duties authorized by law.
    For research purposes, including studying and comparing the patients who received one form of care versus those who received another form of care for the same condition.
    Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counterintelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
    For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws.
    Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.
    V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

    Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
    VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

    The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
    The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
    The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
    The Right to See and Get Copies of Your PHI. Other than “session notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.
    The Right to Get a List of the Disclosures I Have Made.You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.
    The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
    The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.
    EFFECTIVE DATE OF THIS NOTICE

    This notice went into effect on 10/17/2023

    Acknowledgement of Receipt of Privacy Notice

    Under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

  • The Wellness Center of Oneonta, LLC.

     PRACTICE & TELEHEALTH POLICIES

    Appointments and Cancellations: If you schedule a live phone/video appointment, please provide at least 24 hours’ notice to cancel or reschedule. Any applicable late-cancellation/no-show fee will be disclosed before the appointment is scheduled. A chart-review evaluation does not create a missed live appointment unless a specific appointment time was scheduled.

    Communication: Telephone, email, portal, and text communication are for routine care coordination and are not appropriate for emergencies. Electronic communication can have privacy limitations. If you have an emergency, call 911 or go to the nearest emergency department.

    Telehealth: Telehealth may include telephone, video, or asynchronous review of information you submit. Telehealth has limitations because a provider may not be able to perform a hands-on physical examination or directly observe all clinically relevant findings. A provider may require additional records, laboratory testing, a phone/video visit, an in-person examination, or referral before treatment is prescribed.

    Alabama Telehealth Requirements: Before a telehealth medical service is completed, your identity and physical location (city and state) will be verified, the provider’s identity and credentials will be disclosed to you, and your consent to telehealth will be documented. The provider will apply the same professional standard of care required for an in-person medical service.

    Follow-up: After provider evaluation, you will receive treatment/follow-up information and instructions for obtaining appropriate follow-up or emergency care. Alabama law may require an in-person visit or referral when repeated telehealth services are provided for the same unresolved condition.

    WHY / BUILD NOTE: This replacement aligns the patient-facing policy with the Alabama Board’s current telemedicine summary. The clinic still needs internal procedures to actually perform identity/location verification and track the >4 visits/12 months rule.

    BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

  • INFORMED CONSENT FOR CONSULTATION

    I give permission for The Wellness Center of Oneonta, LLC. to receive a consultation by a physician via telemedicine. The physician will decide whether I am a candidate for treatment for medication for weight loss.

    The medication is given subcutaneously weekly and may have some side effects such as mild nausea or stomach cramping as person adjust to it. Some patients also experience indigestion, but this is usually mild and relieved with over-the-counter antacids. Persons with a family history of thyroid cancer or multiple endocrine neoplasia syndrome, or a history of pancreatitis will be precluded from being prescribed this medication.

    I fully understand the nature of the medication described above and the possible side effects. I agree to pay a medical consultation fee of $49 before completion of my visit and $35 for follow-up visits every 3 months, thereafter. I also agree to $75 cancelation/no show fee if you are unable to make your appointment without giving at least 24 hours prior notice. I understand I am enrolling in a weight loss program, but should the doctor not clear me medically to receive the treatment or I choose not to enroll in weight loss program, my initial payment of $49 will not be refunded. I consent to treatment by The Wellness Center of Oneonta LLC. indicated below. I acknowledge that these services are considered to be elective treatments, and that they are not covered by Medicare or most other insurance providers.

    I have read and understand the information provided by The Wellness Center of Oneonta LLC.

  • PHYSICAL LOCATION FOR TELEHEALTH ENCOUNTER

  • Patient statement: “I understand that telehealth care is considered to occur where I am physically located. If my location changes before the provider completes my evaluation, I will notify the Wellness Center.”

  • How would you prefer to be evaluated?*
  • Date*
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  • Next Step: Provider Review & Consultation Fee

    Once your intake form has been submitted, a member of our team will contact you to collect the $49 consultation fee. After payment is received, a licensed medical provider will review your information through your preferred consultation method—either a Chart Review Only or a Phone Consultation.

    If approved for treatment, we will discuss your personalized treatment plan, medication options, and pricing before any prescription is processed or charged.

    No medication charges will be incurred without your approval.

  • No medication charges will be incurred without your approval. Submission of this form does not guarantee approval for treatment. All prescriptions are issued only when medically appropriate after provider review.

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