Male Patient Registration Form

Patient Information:

Parent / Guardian (REQUIRED IF PATIENT IS UNDER 21 YEARS):

NOTE: Per NC Law, Both Parents can be held responsible for medical bills for minors, a medical practice is NOT bound by any separation agreement, divorce or child support order.

In case of an emergency, who would you like to be contacted?

By signing, you agree the information above is correct and give permission for Lamond Family Medicine and Blue Sky to file claims on your behalf.

HIPAA CONSENT: Without signed consent, we can NOT share information regarding your medical care, including family. Please list anyone you would like to have this information below. (leave blank if you would not like any additional individuals to have information regarding your care.

Financial Policy and Signature on File

I authorize the release of any medical pertinent information to my consulting provider, if needed and as necessary to process insurance claims, insurance applications and prescriptions. I also authorize payment of benefits to both LaMond Family Medicine and Blue Sky MD.

I understand that I am financially responsible for all services rendered including for the following reasons: 1) no proper referral at the time of service or referral is invalid/expired 2) incorrect/invalid insurance information given or failure to give new updated insurance information 3) Expenses not covered by insurance 4) deductible not met 5) services rendered are deemed medically unnecessary by insurance. Failure of insurance company to pay does not excuse patient’s financial responsibility. It is patient’s responsibility to know what is and is not covered by their insurance policy/plan (including Medicare beneficiaries).

Payment is required for all services at the time they are rendered including co-payments and any outstanding balances. You may be balance billed per your insurance contract guidelines for any amount not collected or known at the time of service. Outstanding balances not addressed/ paid in a timely fashion may be forwarded to collections and may be reported to your credit.

Returned Checks: In the event a check is returned for Non Sufficient Funds, we will assess a $25.00 charge in addition to your current balance to cover the bank charges incurred by our office due to Non Sufficient Funds. Your signature below signifies your understanding and willingness to comply with the policies of this office and your insurance plan.

Prescriptions: Please bring a list of your current medications with you at the time of your appointment. We will NEVER call in ANY pain medications, antibiotics or narcotics to any drug store. If you need a prescription refill, please call your pharmacy and ask that they fax a refill request to our office. Our providers will review the request and refill the prescription by return fax or we may request you make a follow up appointment if necessary. Please allow 24 hrs for a response to refill requests. Samples are given at scheduled appointments ONLY and can ONLY be given by the doctor.

Missed Appointments: We charge $50.00 for any no show appointment not cancelled within 24 hrs. This charge will be billed directly to you. Please help us to serve you better by keeping all scheduled appointments. If you “no show” to 3 appointments within 1 year, we have the right to dismiss you from our practice for non compliance.

HIPAA COMPLIANCE STATEMENT - THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

At this practice, we are committed to protecting your privacy. We comply with all federal, state, and local laws. This notice describes how we use your health information. It describes some of your rights and some of our responsibilities. UNDERSTANDING YOUR HEALTH RECORD/INFORMATION - Each time you visit our offices, we record your symptoms, physical examination, test results, diagnosis, and treatment. This information enables us to plan for your care, communicate with others who care for you, report to your insurance carrier, bill for our work, and improve the quality of our care to you. YOUR RIGHTS - Although your medical chart belongs to our practice, the information contained in the chart is yours. You have the right to inspect your records, obtain a copy of your chart for a small fee, correct your records, and tell us not to release your information to certain parties.
OUR RESPONSIBILITIES - We are required to maintain the privacy of your health information, send needed health information to other medical providers, and release information to insurance companies, certain government agencies, and others. We may be required to release some information, even without your permission.
EXAMPLES OF HOW YOUR INFORMATION IS USED - Your health information will be recorded and used to plan your treatment. Reports may be sent to other doctors to help them plan your treatment. Claims will be sent to your insurance company. The information in the claims will include confidential information such as your name, address, diagnosis, and treatment. In providing your care, we may communicate with other individuals or businesses. Examples include other physicians and/or laboratories. To protect your privacy, we ask our business associates to safeguard your information.
OTHER NOTICES - We may leave a message at your home, at your business, on your answering machine or on your voicemail. We may mail you a postcard or other written notices. We may need to disclose your information to your family members or other people helping with your care. In doing so, we will use our best judgment. We may disclose information to others as required by law or if subpoenaed. If you were injured on the job, we will need to disclose your health information to your workers compensation insurance company. We may, from time to time, update these policies.
FOR MORE INFORMATION, QUESTIONS OR TO REPORT A PROBLEM - If you have concerns or would like additional information, you may contact the Office Manager.

Health History:

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

Family Health History:

All questions contained in this questionnaire are optional and strictly confidential.

Mental Health:

Weight Intake and History

Patient Information:

Eating habits over the past year:

Male Symptom AMS Questionnaire

Which of the following symptoms apply to you at this time?

Please mark yes or no on the questions below:

Patient informed Consent for Weight Loss Program

I. Procedure and Alternatives:

am voluntarily enrolling in/or have enrolled in an aggressive weight management program, through Blue Sky MD. I hereby authorize Blue Sky MD and whomever they designate as assistants, to provide medical care to assist me in my weight reduction efforts, to achieve the goals of weight loss and weight maintenance. I understand that such care may include but is not limited to physical examination, laboratory screening, EKG testing, intense follow-ups, psychological therapy, instruction in behavior modification techniques, nutritional counseling, fitness counseling, vitamin supplementation, and may involve the use of appetite suppressants. I further understand that if appetite suppressants are used, they may be used for durations exceeding those recommended in the product literature, and when indicated, in higher doses than the dose indicated in the appetite suppressant labeling.

2. I have read and understand my doctor’s statements that follow:“Medications, including the appetite suppressants, have labeling worked out between the makers of the medication and the Food and Drug Administration. This labeling contains, among other things, suggestions for using the medication. The appetite suppressant labeling suggestions are generally based on shorter term studies (up to 12 weeks) using the dosages indicated in the labeling. “As a bariatric physician, I have found the appetite suppressants helpful for periods far in excess of 12 weeks. As a provider, I am not required to use the medication as the labeling suggests, but I do use the labeling as a source of information along with my own experience, the experience of my colleagues, recent longer term studies and recommendations of university based investigators. Based on these, I have chosen, when indicated, to use the appetite suppressants for longer periods of time and at times, in increased doses. “Such usage has not been as systematically studied as that suggested in the labeling and it is possible, as with most other medications, that there could be serious side effects (as noted below). “As a bariatric physician, I believe the probability of such side effects is outweighed by the benefit of the appetite suppressant use for longer periods of time. However, you must decide if you are willing to accept the risks of side effects, even if they might be serious, for the possible help the appetite suppressants use in this manner may give.”

3. I understand it is my responsibility to follow the instructions carefully and to report to the doctor treating me for my weight any significant medical problems that I think may be related to my weight control program as soon as reasonably possible. I agree to disclose any past or current medical conditions or problems that may exist or would be consistent with any of the conditions or problems in the cautionary statement. I have read and I understand that the conditions and contraindications that are outlined in the cautionary statement.

4. I understand the purpose of this treatment is to assist me in my desire to decrease my body weight and to maintain this weight loss. I understand my continuing to receive the appetite suppressant will be dependent on my progress in weight reduction and weight maintenance.

5. I understand there are other ways and programs that can assist me in my desire to decrease my body weight and to maintain this weight loss. In particular, a balanced calorie counting program or an exchange eating program without the use of the appetite suppressant would likely prove successful if followed, even though I would probably be hungrier without the appetite suppressants.

6. Patients, who are pregnant or are trying to conceive, should not be taking prescription appetite medications. Please notify our staff or doctor should you have any missed or irregular periods. Mothers who are breastfeeding should not use prescription appetite suppressants and patients with a history of alcohol and/or drug abuse should not use appetite suppressants.

I. Risk of Proposed Treatment:

I understand this authorization is given with the knowledge that the use of the appetite suppressants for more than 12 weeks and in higher doses than the dose indicated in the labeling involves some risks and hazards. The more common include: nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, psychological problems, medication allergies, high blood pressure, rapid heartbeat and heart irregularities. Less common, but more serious, risks are primary pulmonary hypertension and valvular heart disease, heart attack and stroke. Physical injury can result from such things as increased exercise and activity. GI side effects, such as constipation, diarrhea, and/or bloating, or development of gallbladder disease from rapid weight loss. These and other possible risks could, on occasion, be serious or fatal. Age may also be a factor in prescribing these medications and is at the discretion of the examining and treating physician. Phentermine has not been studied in patients older than 65 or younger than 18, therefore we cannot guarantee the safety or effectiveness of the medication in these age groups. Some patients may not be good candidates for prescription appetite suppressant use due to various medical reasons.

II. Risk of Proposed Treatment:

I understand this authorization is given with the knowledge that the use of the appetite suppressants for more than 12 weeks and in higher doses than the dose indicated in the labeling involves some risks and hazards. The more common include: nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, psychological problems, medication allergies, high blood pressure, rapid heartbeat and heart irregularities. Less common, but more serious, risks are primary pulmonary hypertension and valvular heart disease, heart attack and stroke. Physical injury can result from such things as increased exercise and activity. GI side effects, such as constipation, diarrhea, and/or bloating, or development of gallbladder disease from rapid weight loss. These and other possible risks could, on occasion, be serious or fatal. Age may also be a factor in prescribing these medications and is at the discretion of the examining and treating physician. Phentermine has not been studied in patients older than 65 or younger than 18, therefore we cannot guarantee the safety or effectiveness of the medication in these age groups.

Some patients may not be good candidates for prescription appetite suppressant use due to various medical reasons.

III. Risks Associated with Being Overweight or Obese:

I am aware that there are certain risks associated with remaining overweight or obese. Among them are tendencies to high blood pressure, to diabetes, to heart attack and heart disease, and to arthritis of the joints, hips, knees and feet, and many other diseases. Obesity and overweight also reduces my overall life expectancy. I understand these risks may be modest if I am not very much overweight but that these risks can go up significantly the more overweight I am. I recognize these current risks to my health as unacceptable and wish to aggressively treat my weight by enrolling in this program.

IV. No Guarantees:

I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I also understand that I will have to continue watching my weight all of my life if I am to be successful.

V. Patient’s Consent:

I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained, or any questions I have concerning them have not been answered to my complete satisfaction. I have been urged to take all the time I need in reading and understanding this form and in talking with my doctor regarding risks associated with the proposed treatment and regarding other treatments not involving the appetite suppressants.

I further understand that upon withdrawal from this program, I will not be entitled to a refund of any previously paid monies.

WARNING: IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THE PROPOSED TREATMENT, OR ANY QUESTIONS WHATSOEVER CONCERNING THE PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK YOUR DOCTOR NOW BEFORE SIGNING THIS CONSENT FORM

Blue Sky MD Medication Agreement

I understand and voluntarily agree.

I will keep and be on time for all my scheduled appointments with the provider and other members of the treatment team.

I will keep the medicine safe, secure and out of the reach of children. If the medicine is lost or stolen, I understand it will not be replaced until my next appointment, and may not be replaced at all.

I will take my medication as instructed and not change the way I take it without first talking to the provider or other member of the treatment team.

I will make sure I have an appointment for refills. If I am having trouble making an appointment, I will tell a member of the treatment team immediately.

I will treat the staff at the office respectfully at all times. I understand that if I am disrespectful to staff or disrupt the care of other patients my treatment will be stopped.

I will not sell this medicine or share it with others. I understand that if I do, my treatment will be stopped.

I will tell the provider all other medicines that I take, and let him/her know right away if I have a prescription for a new medicine.

I will use only one pharmacy to get all of my medicines.

I will not use illegal drugs such as heroin, cocaine, marijuana, or amphetamines. I understand that if I do, my treatment may be stopped.

I consent to drug testing and counting of my pills on an as needed basis. I consent to allow Blue Sky MD providers and staff to review any state prescription drug monitoring websites.

I understand that I may lose my right to treatment in this office if I break any part of this agreement.