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

First Name* This field is required.

Last Name* This field is required.

Gender* This field is required.

Female

Male

Non-binary

Prefer not to say

Other

Phone Number* This field is required.

Please enter a valid phone number.

Email Address* This field is required.

example@example.com

Street Address* This field is required.

City* This field is required.

State* This field is required.

ZIP Code* This field is required.

Emergency Contact Name* This field is required.

First Name

Middle Name

Last Name

Emergency Contact Phone Number* This field is required.

Please enter a valid phone number.

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

Are you currently taking any medications or supplements?* This field is required.

Yes

List all medications or supplementsPlease list all medications, vitamins, supplements, and herbal products you currently take, including dosage if known.

Medication Start DatesPlease provide the approximate start date for each medication or supplement listed above, if known.

Medication changes in the past 6 months* This field is required.

Yes

N/A

List all of the changes if applicable

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

Other

FAMILY MEDICAL HISTORY - Other (please specify)

Do you have any allergies (including medications, foods, or environmental)?* This field is required.If Yes, Please list all allergies

Have you had any previous surgeries or hospitalizations?* This field is required.

Yes

Please provide details of all surgeries or hospitalizations.

Please provide all surgery dates.

Other medical concerns

How much water do you drink daily?* This field is required.

Do you smoke?* This field is required.

Yes

Former smoker

Do you consume alcohol?* This field is required.

Yes

Occasionally

What are your primary treatment goals? (Select all that apply)* This field is required.

Forehead Lines

Frown Lines (Between Eyebrows)

Crow's Feet

Brow Lift

Lip Flip

Preventative Botox

General Facial Rejuvenation

Other

None

(Other) Please describe your treatment goals.

Have you previously received Botox or other neurotoxin treatments?* This field is required.

Yes

Please provide the approximate date of your most recent treatment and any additional details.

Have you experienced any complications or adverse reactions from Botox or neurotoxin treatments in the past?* This field is required.

Yes

Please provide details regarding the complication or adverse reaction.

Are you currently pregnant, trying to become pregnant, or breastfeeding?* This field is required.

Yes

Please provide additional details.

Are you currently taking blood thinners, aspirin, anti-inflammatory medications, or supplements that may increase bruising?* This field is required.

Yes

Please list all medications and supplements currently being taken.

Is there anything else you would like our medical provider to know prior to your consultation?

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.

Zelle details: Nadia Lopez, hopehealthservicesinc@proton.me

Zelle Payment Confirmation Screenshot* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.0MB

Upload a File

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

Date Payment Was SentPlease select the date your Zelle payment was submitted.

Date

Patient Name* This field is required.Your name entered below will automatically appear on your consent forms and treatment documents.

Date of Birth* This field is required.Your date of birth will automatically appear on your consent forms and treatment documents.

Date

HOPE HEALTH SERVICES INC. BOTOX/NEUROTOXIN– 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.

Acknowledgment* This field is required.

I have read, understand, and agree to the terms outlined in this Treatment Consent & Release.

Consent Date* This field is required.The date entered below will be recorded as the official date of your electronic consent.

Date

Patient Signature* This field is required.

Patient Name* This field is required.Your name entered below will automatically appear on your consent forms and treatment documents.

Date of Birth* This field is required.Your date of birth will automatically appear on your consent forms and treatment documents.

Date

HOPE HEALTH SERVICES INC. NEUROTOXIN 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.

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.

Date* This field is required.The date entered below will be recorded as the official date of your electronic consent.

Date

Electronic Signature* This field is required.

Appointment Date* This field is required.

Date

Preferred Appointment Time Block* This field is required.Last appointment scheduled 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

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.

PRINT NAME* This field is required.

DATE OF BIRTH* This field is required.

Date

PRE-TREATMENT INSTRUCTIONS
We recommend avoiding anti-inflammatories (such as Ibuprofen, Motrin, Advil, etc.) and aspirin one week prior to treatment to reduce the risk of bruising/swelling in the treatment area. Omega-3 fatty acids, Vitamin E, and Flax Seed Oil taken daily can also contribute to bruising, so they should also be avoided for one week prior to treatment.

POST-TREATMENT INSTRUCTIONS
Perform frequent dynamic facial expressions/exercises in the treated areas for the first hour after treatment (Frown, smile, raise eyebrows, etc.). Do not rub or massage the treatment sites for at least three hours after the procedure. RESULTS OF TREATMENT WITH NEUROTOXINS MAY TAKE 7-10 DAYS TO TAKE FULL EFFECT. Not all patients will respond to the treatment, and not all patients will have full relaxation of the targeted muscle groups. In some cases, only partial muscle relaxation occurs, and additional treatment may be needed to achieve full relaxation. The benefits may last 2-6 months and will vary per person. A touch-up may be necessary in 1-2 weeks; however, touch-ups cannot be done after the 2-week period has passed. Please inform the medical staff if the resolution of lines has not taken effect after the 8th day. A fee at our standard per-unit rate MAY be charged if additional neurotoxin is needed after the first injection. The medical staff has reviewed all pre- and post-Neurotoxin Cosmetic treatment instructions and answered all questions.

Date* This field is required.

Date

Patient Signature* This field is required.

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.

Electronic Signature* This field is required.

Date* This field is required.

Date

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