New Patient Forms

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Step 1 of 9 Patient Information

New Patient Registration Forms

Patient Name DOB Height Occupation Address City State Zip Contact Phone Number Email address

Phone type Cell Home

Sex Male Female

Emergency Contact Phone Relationship Primary Physician Phone Date of last seen by your doctor

How did you hear about us? Web Search Facebook Referral

Name of person who referred you

Weight Loss History Why do you want to lose weight?

What is your short-term weight loss goal? Lose lbs. What is your long-term weight loss goal? Lose lbs. When was the last time you were happy with your weight? How much did you weigh then? lbs.

Have you used any prescription diet pills in the past? Yes No

If yes, how long ago? years What medication?

Did you lose weight on the medication? Yes No

If yes, how much weight did you lose? lbs.

Have you used GLP1 medications before? Yes No

If yes - What medication?

Did you lose weight? Yes No

If yes, how much did you lose? lbs.

Women Only

First day of last menstrual cycle? If N/A why?

Are you pregnant or planning to get pregnant? Yes No N/A

Are you breastfeeding? Yes No N/A

Acknowledgement of Receipt of Notice of Privacy Information Practices

According to HIPPA (Health Insurance Portability and Accountability Act), patients have the right to confidential care. All information whether it is medical, social, written, spoken, electronic, or computer generated must be kept confidential.

The following will describe the ways in which we may use or disclose your health information and also describe your rights and our obligations concerning such uses or disclosures.

Our obligations:

We may disclose your health information to other healthcare providers who are involved in your health care to coordinate your care and services.

We may use or disclose your health information so that we may bill and receive payment from or your insurance.

We may use your health information for the purpose of contacting you to remind you of your appointment.

We may disclose your health information to a family member when we have your verbal or written agreement to do so, or we can infer that you would not object to such disclosures.

We may disclose your health information when it is required by law

Your rights:

You have the right to inspect and copy your health information

You have the right to request an amendment of your health information

You have the right to request an accounting of the disclosures of your health information made by us.

You have the right to request a restriction or limitation on the health information we use or disclose about you.

You have the right to request that we communicate with you about your health care in a certain way

You have the right to revoke in writing your written authorization at any time.

You have the right to receive a detailed paper copy of the "Notice of Privacy Information Practices"

If you have any questions and would like additional information or if you believe your privacy rights have been violated, you may file a complaint with the Compliance Officer by calling the Compliance Hotline toll free at (877) 309-4362. You may also file a complaint with the Secretary of the Department of Health and Human Services at www.osdhhs.gov.

I acknowledge receipt of the Notice of Privacy Information Practices.

Print name Date

CONSENT OF TREATMENT

authorize Masoud Isat, FNP & DeVry Anderson, MD and/or any of their assistants, to provide medical care to me, including but not limited to the treatment of my weight problem and any coexisting medical conditions. This may involve but not be limited to history taking, in-office testing, physical examination, and any required additional laboratory testing.

I understand that my program may consist of a healthy diet regimen, a regular exercise program, behavior modification measures, B12 / Fat Burner injections, GLP1 injections and if indicated other appetite suppressans.

I further understand that appetite suppressants may be used for a longer duration that exceeds the recommended one described in the medication package insert or that set forth by the FDA. These medications have been used safely and successfully in private medical settings as well as in academic centers for periods exceeding those recommended in the product literature.

I understand that I may be prescribed medications for medical conditions other than those relating to my weight needs according to general medical practice standards.

I understand that any medical intervention has associated potential risks and benefits. The risks of appetite suppressants medications may include but are not limited to nausea, fatigue, indigestion, insomnia, headaches, dry mouth, constipation, high blood pressure and rapid heartbeat. In rare instances these and other possible risks could be serious or even fatal.

The benefits of successful weight management may include but are not limited to improved overall health, lower risk of developing serious diseases with at times fatal complications, such as diabetes, breathing problems, joint degeneration, high blood pressure, heart disease, circulation problems, heart attack, and stroke.

I understand that much of the success of the program will depend on my active participation. We at Unique Weight Loss and Family Practice, PLLC do not guarantee or assure you that the program will be successful, especially if you do not comply with your provider's instructions.

I also understand and affirm that I have not been solicited by anyone who is affiliated with Unique Weight Loss and Family Practice prior to signing this consent form. Instead, I contacted the clinic voluntarily to make my appointment.

I have read and fully understand this consent form, and I realize I should not sign it if all items have not been explained satisfactorily to me.

I have read and understand the consent of treatment.

Patient's Name

Signature

Date

Financial Policy & Important Reminders

Thank you for selecting Unique Weight Loss and Family Practice for your health care needs. We are honored to be of service to you and your family. This is to inform you of our financial policy. Please be advised that payment for all services will be due at the time services are rendered.

For your convenience, we accept all types of credit cards, HSA and FSA cards.

PATIENT COMMUNICATION

(Please initial each type of messaging you'd like to receive reminders on)

Email reminders of your appointment. Initials. Text Message reminders, promotions and greetings. There is a $50 Fee for a No Show, and for Rescheduling or Cancelling your appointment without giving us 24-hour notice. B12 / Fat Burner injections must be used within 5 weeks of purchase or your next follow up appointment whichever comes first.

Patient's Name

Signature

Date

Review & Submit

I confirm the information is accurate and ready to submit.