Hope Health Services – Weight Management Program Consultation & Medical Intake Form

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First Name* This field is required.
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Last Name* This field is required.
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Age
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Gender* This field is required.
Female
Male
Non-binary
Prefer not to say
Other
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Phone Number* This field is required.
Please enter a valid phone number.
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Email Address* This field is required.
example@example.com
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Street Address* This field is required.
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City* This field is required.
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State* This field is required.
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Please Select
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Texas
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Other
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ZIP Code* This field is required.
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Emergency Contact Name* This field is required.
First Name
Middle Name
Last Name
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Emergency Contact Phone Number* This field is required.
Please enter a valid phone number.
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Medical conditions* This field is required.
High Blood Pressure
Heart Disease
Stroke
Diabetes
High Cholesterol
Thyroid Disorder
Asthma
Sleep Apnea
Kidney Disease
Liver Disease
Cancer
PCOS
Anxiety
Depression
None
Other
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Are you currently taking any medications or supplements?* This field is required.
Yes
No
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List all medications or supplementsPlease list all medications, vitamins, supplements, and herbal products you currently take, including dosage if known.
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Medication Start DatesPlease provide the approximate start date for each medication or supplement listed above, if known.
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Medication changes in the past 6 months* This field is required.
Yes
No
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List all of the changes
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FAMILY MEDICAL HISTORYPlease indicate whether any of your immediate family members (parents, siblings, grandparents, or children) have been diagnosed with any of the following conditions. (Select all that apply)
No Known Family Medical History
Obesity
Diabetes
Prediabetes
High Blood Pressure
High Cholesterol
Heart Disease
Heart Attack
Stroke
Thyroid Disorder
PCOS (Polycystic Ovary Syndrome)
Sleep Apnea
Kidney Disease
Liver Disease
Fatty Liver Disease
Cancer
Breast Cancer
Colon Cancer
Ovarian Cancer
Prostate Cancer
Autoimmune Disease
Depression
Anxiety
Substance Abuse Disorder
Eating Disorder
Metabolic Syndrome
Arthritis
Osteoporosis
Alzheimer's Disease or Dementia
None
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Do you have any allergies (including medications, foods, or environmental)?* This field is required.If Yes, Please list all allergies
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Have you had any previous surgeries or hospitalizations?* This field is required.
Yes
No
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Please provide details:
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Surgery dates
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Other medical concerns
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Current Weight (lbs)* This field is required.
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Height* This field is required.
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Goal Weight (lbs)* This field is required.
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Have you attempted weight loss before?* This field is required.
Yes
No
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What weight loss methods have you tried?Select all that apply
Diet Programs
Exercise Programs
Weight Loss Medications
Personal Trainer
Meal Replacement Programs
Calorie Tracking
Intermittent Fasting
Keto Diet
Weight Watchers
Bariatric Surgery
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What are your primary weight management goals?* This field is required.
Lose Weight
Maintain Current Weight
Reduce Body Fat
Improve Metabolism
Increase Energy Levels
Improve Eating Habits
Develop a Healthier Lifestyle
Improve Blood Sugar Control
Improve Blood Pressure
Lower Cholesterol
Improve Mobility & Physical Activity
Increase Confidence & Self-Esteem
Improve Overall Health
Receive Medical Weight Loss Support
Learn Healthy Nutrition Strategies
Establish Long-Term Weight Management Habits
Other
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Previous weight management treatmentsPlease select any previous weight management treatments or programs you have participated in. Select all that apply.
None
Diet Programs
Medical Weight Loss Program
Weight Loss Medications
Semaglutide (Ozempic/Wegovy)
Tirzepatide (Mounjaro/Zepbound)
Nutritional Counseling
Personal Training
Meal Replacement Program
Bariatric Surgery
Weight Loss Injections
Commercial Weight Loss Programs (Weight Watchers, Jenny Craig, etc.)
Other
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How many days per week do you exercise?* This field is required.
Please Select
Please Select
0 days
1-2 days
3-4 days
5-6 days
7 days
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How much water do you drink daily?* This field is required.
Please Select
Please Select
Less than 32 oz
32-64 oz
65-96 oz
More than 96 oz
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Do you smoke?* This field is required.
Yes
No
Former smoker
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Do you consume alcohol?* This field is required.
Yes
No
Occasionally
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Please describe your typical daily eating habits.
Excellent – Consistently Healthy and Balanced
Good – Usually Healthy with Occasional Indulgences
Fair – Some Healthy Choices but Inconsistent
Poor – Frequently Eat Processed or Fast Foods
Following a Structured Meal Plan
Vegetarian
Vegan
Keto / Low-Carb
Intermittent Fasting
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Any additional weight management concerns or goals?
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Consultation payment is required before appointment scheduling can be confirmed. Please send Zelle to: Nadia Lopez (hopehealthservicesinc@proton.me) and upload your Zelle payment confirmation below.
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Zelle details: Nadia Lopez, hopehealthservicesinc@proton.me
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Zelle Payment Confirmation Screenshot* This field is required.
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Zelle Confirmation Number* This field is required.
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Amount PaidPlease confirm the amount submitted for your consultation reservation fee. The required consultation fee is $200 and will be credited toward eligible treatment or services purchased
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Date Payment Was SentPlease select the date your Zelle payment was submitted.
Date
Month
Day
Year
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Patient Name* This field is required.Your name entered below will automatically appear on your consent forms and treatment documents.
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Date of Birth* This field is required.Your date of birth will automatically appear on your consent forms and treatment documents.
Date
Month
Day
Year
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HOPE HEALTH SERVICES INC. WEIGHT MANAGEMENT PROGRAM – TREATMENT CONSENT & RELEASE

I acknowledge that the practice of skin care and advanced medical aesthetic treatments including facials, peels, laser treatments, Intense Pulsed Light devices with Radio-Frequency, dermal injections for wrinkle correction, and facial and body contouring, and various other beauty treatments, are not an exact science and no specific guarantees can or have been made concerning expected results.

I understand that some clients experience more change and improvements than others. In virtually all cases, multiple treatments are required to achieve a difference. I also realize that the following risks and hazards may occur in connection with any particular treatment, including, but not limited to, unsatisfactory results, poor healing, discomfort, redness, blistering, nerve damage, scarring, changes in skin pigmentation, and increased hair growth.

I understand that, even with precautions taken in my treatment, not all risks can be known in advance. Given the above, I understand that response to treatment varies on an individual basis and that specific results are not guaranteed. I also agree to hold harmless and release from any liability Hope Health Services Inc., or any of its officers, medical directors, for any condition or result, known or unknown, that may arise as a result of any treatment that I receive.
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Acknowledgment* This field is required.
I have read, understand, and agree to the terms outlined in this Treatment Consent & Release.
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Consent Date* This field is required.The date entered below will be recorded as the official date of your electronic consent.
Date
Month
Day
Year
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Patient Signature* This field is required.
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Patient Name* This field is required.Your name entered below will automatically appear on your consent forms and treatment documents.
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Date of Birth* This field is required.Your date of birth will automatically appear on your consent forms and treatment documents.
Date
Month
Day
Year
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HOPE HEALTH SERVICES INC. WEIGHT MANAGEMENT PROGRAM PHOTOGRAPHY CONSENT

This consent form authorizes Hope Health Services Inc., or its individual members, to take my photographs for my chart. I consent that the photographs taken of me at any Hope Health and Beauty locations may be used for marketing, medical research, education, or scientific purposes.

I understand that such photographs and information relating to my case may be published and republished, either separately or in conjunction with each other, in professional journals or medical books, or used for any other purpose which my health care professional may deem proper in the interest of medical education, knowledge, research, or marketing.

I understand that whenever possible, my identity will be masked with the use of cropping or blocking distinguishing features. I waive any rights that I may have to any claims for payment or royalties in connection with any exhibition, televising, or publication of these photographs.

I release and hold harmless the clinic, staff, and consultants from any liability in connection with the use of such materials. I understand that under no circumstances will any such publication, film, photograph, videotape, or any material contain my name unless voluntarily disclosed by me. Your refusal to consent to the use of your photographs will in no way influence your treatment.
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Acknowledgment* This field is required.
I have read and understand the Photography Consent and authorize Hope Health Services Inc. to photograph me and use such photographs as described above.
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Date* This field is required.The date entered below will be recorded as the official date of your electronic consent.
Date
Month
Day
Year
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Electronic Signature* This field is required.
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Appointment Date* This field is required.
Date
Month
Day
Year
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Preferred Appointment Time Block* This field is required.Last scheduled appointment at 8:00 PM
8:00 AM – 11:00 AM
11:00 AM – 2:00 PM
2:00 PM – 5:00 PM
3:00 PM – 6:00 PM
6:00 PM - 9:00 PM
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A member of Hope Health Services will contact you to confirm your appointment date and time. Appointment requests are subject to provider approval and availability.
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Acknowledgment* This field is required.
I certify that the information provided in this form is accurate and complete to the best of my knowledge. I understand that treatment recommendations will be determined by the medical provider after review of my medical history and consultation.
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Electronic Signature* This field is required.
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Date* This field is required.
Date
Month
Day
Year
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