Weight Loss Clinic
Snatched Wellness - Weightloss Pens
Consultation Consent Forum
Please read your disclaimer and after care.
Name
First Name
Last Name
Gender
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Female
Other
D.O.B
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Month
-
Day
Year
Date
Email
example@example.com
Phone Number
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Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Height
BMI
Do you understand the information you have been provided?
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No
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Do you feel sufficient information has been provided to you, to enable you to consent?
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No
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Has your consent been freely given?
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No
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Do you have any medical conditions?
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No
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Are you pregnant or breastfeeding?
Yes
No
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Do you have a neuromuscular disease (e.g. MS, ALS, motor neuropathy myasthenia gravis, or Lambert-Eaton syndrome)?
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No
Comment
Do you have an autoimmune disease?
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No
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Do you have any skin conditions?
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No
Comment
Do you have any known allergies or have ever had anaphylaxis?
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No
Comment
Do you have any active infection at the intended site of procedure?
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No
Comment
Are you taking antibiotics or other prescription medications?
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No
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Is there any other Medical and/or Social History that we should know? If so, please provide full detail here.
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No
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What are your aims/motivations for having the procedure and the desired outcome? Please provide full details here.
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No
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Have you had this or a similar treatment before? If so, did you experience any problems? Please provide full details here.
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No
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Do you have any concerns? If so, please provide full details here.
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No
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Is there anything else we should know? Please provide full details here.
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No
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I will retain this information throughout the course of my treatment and refer to it as required.
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No
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