Weight Loss Program Form | Cornelia, GA

Date:

Patient's Name:

Date of Birth

Sex:

F

M

Address:

City:

State:

Zip Code:

Cell #:

Home#:

Email Address:

Work #:

Marital Status:

Date of Injury if Applicable:

Emergency Contact Information:

Emergency Contact Information:

Name:

Phone#:

Relationship:

Payment Agreement:

Payment Agreement: I understand and that I am fully responsible for the total payment of all procedures and treatment performed at Spectrum Healthcare for the above listed patient – this includes any treatment that is not a benefit of any insurance that I have. I understand that all fees for services are due and payable at the time the services are rendered. I further acknowledge and agree that I am personally responsible for payment of all services and that billing to my insurance company in provided as a convenience. Spinal Rehab and Healthcare will bill my insurance company. If my insurance company denies the claim, I am ultimately responsible for all fees.

I agree to pay for Medical Services rendered at Spectrum Healthcare. I understand that I am responsible for the fees incurred during my treatment.

X

Date:

If parent or guardian is completing this form for the patient, please print, sign, and date here:

X

Print:

Date:

Patient Health Information Consent For

Patient Health Information Consent Form

The patient understands and agrees to allow Spinal Rehab and Healthcare, LLC to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow Spinal Rehab and Healthcare, LLC to submit requesteThe patient understands and agrees to allow Spinal Rehab and Healthcare, LLC to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow Spinal Rehab and Healthcare, LLC to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment.

Additionally, the patient acknowledges that Spinal Rehab and Healthcare, LLC utilizes Artificial Intelligence (AI) software to assist in generating accurate and efficient clinical documentation for health records. This technology is used solely to enhance the quality of care and ensure comprehensive documentation of patient encounters.

1. The patient has the right to examine and obtain a copy of his/her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions.

2. A patient's written consent need only be obtained one time for all subsequent care given to the patient in this office.

3. The patient may provide a written request to revoke consent at any time during care. This would not affect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented.

4. For your security and right to privacy, all staff have been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions known by this office to assure that your records are not readily available to those who do not need them.

5. Patients have the right to file a formal complaint with our privacy official about any possible violation of these policies and procedures.

6. If the patient refuses to sign this consent for the purpose of treatment, payment, and health care operations, the physicians have the right to refuse to give care.

I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures. I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures.

Patient's Signature:

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General Medical Information

General Medical Information

My general health is:

Have you ever been in a medical weight loss program?

Yes

No

If Yes: Last visit

Doctor’s Name:

Medications prescribed:

Present Weight:

Desired Weight:

In what time frame would you like to be at your desired weight?

What is the main reason for your decision to lose weight?

When did you begin gaining excess weight? (Give reasons, if known)

What has been your maximum weight (non-pregnant) and when?

Previous diets you have followed:

How often do you dine out?

How often do you eat “fast foods?”

Food dislikes:

Food you crave:

Any specific time of the day or month do you crave food?

Do you drink coffee or tea? How much daily?

Do you drink cola drinks? How much daily?

What are your worst food habits?

What restaurants do you frequent?

Snack Habits:

Describe your usual energy level:

Activity Level

Activity Level: (answer only one)

Activity Level: (answer only one)

Inactive, no regular physical activity with a sit-down job.

Light activity, no organized physical activity during leisure time.

Moderate activity, occasionally involved in sports activities such as weekend golf, tennis, etc.

Heavy activity, consistent lifting, stair climbing, heavy construction, etc., or regular participation in jogging etc. or active sports at least three times per week.

Vigorous activity participation in extensive physical exercise for at least 60 minutes per session 4 times per week.

Behavior style: (answer only one)

Behavior style: (answer only one)

You are always calm and easygoing.

You are usually calm and easygoing.

You are sometimes calm with frequent impatience.

You are seldom calm and persistently driving for advancement.

You are never calm and have overwhelming ambition.

You are hard-driving and can never relax.

Please describe your general health goals and improvements:

Please describe your general health goals and improvements you wish to make:

This information will assist us in assessing your particular problem areas and establishing your medical management. Thank you for your time and patience in completing this form.

Who is your family doctor?

Date of last visit?

List any medications you are currently taking including strength and how taken: If you have a list of medications, please allow us to make a copy for you.

Name:

Dosage:

How Often:

Name:

Dosage:

How Often:

Name:

Dosage:

How Often:

Name:

Dosage:

How Often:

Name:

Dosage:

How Often:

Name:

Dosage:

How Often:

Allergies

Current Alcohol Consumption:

Type:

Beer

Wine

None

Frequency:

Casual

Moderate

Heavy

Never

If you have quit, how long?

Current Tobacco Use:

Type:

Cigarettes

Pipe

Chew

None

How much used daily?

If you have quit, how long?

Are you pregnant?

Yes

No

I hereby attest that I personally completed this form and all the information is true and correct:

Patient:

Date:

PHENTERMINE WEIGHT LOSS PROGRAM INFORMED CONSENT

PHENTERMINE WEIGHT LOSS PROGRAM

INFORMED CONSENT

I request the use of Phentermine, along with strict dietary restrictions for the purpose of weight loss. I understand that as part of the program, I will be given a limited physical, orientation to the program with supporting materials and I will be instructed on how to administer Phentermine myself. I understand that initial blood tests may be necessary to rule out any conditions that would disqualify me from the program. I will obtain these from my own physician or have them ordered through a Spectrum Healthcare provider.

I understand there is no guarantee for the effectiveness of Phentermine. I agree that I am and will be under the care of another medical provider for all other conditions. A Spectrum Healthcare physician can work in conjunction with, but cannot replace, my regular primary care physicians, such as general practitioners or other specialists in family medicine or internal medicine. I understand they can only prescribe Phentermine and medication necessary for this treatment and all other health matters should be through my regular physician(s).

Prior to my treatment, I have fully disclosed any medical conditions or diseases such as history of gallbladder disease, diabetes, autoimmune diseases, HIV, heart disease, liver disease, kidney disease, uncontrolled high blood pressure, seizure disorders, blood disorder (anemia, thalassemia, hemophilia, etc.) emphysema or asthma, and any history of stroke or cancer. These contraindications have been fully discussed with me. Further contraindications are outlined below.

If I fail to disclose any medical condition that I have, I release the doctor and facility from any liability associated with this procedure. Initials:

Contraindications and Warnings

Contraindications and Warnings

Patients with the following should not use Phentermine:

• An allergy to Phentermine

• Those who have taken a monoamine oxidase inhibitor (MAO) within the last 14 days

• Have advanced arteriosclerosis, cardiovascular disease, moderate to severe hypertension, hyperthyroidism, or glaucoma

• Are in an agitated state or have a history of drug or alcohol abuse

• Women who are nursing, pregnant, or plan on becoming pregnant

Patients with the following should take special precautions and consult their doctor before using

Phentermine:

• Allergies to medicines, foods, or other substances

• Those who have diabetes may need a larger dose of insulin while taking phentermine

• Have a brain or spinal cord disorder, hardening of the arteries, high blood pressure, diabetes, or high cholesterol or lipid levels

Side Effects

Side Effects

While Phentermine is generally free of negative side effects, there is the possibility of the following:

• Dry mouth • Diarrhea • Nausea/ Vomiting

• Unpleasant taste • Constipation • Fatigue

• Heartburn • Stomach Pain • Hypertension

• Skin Rash or Itching • Lactic acidosis • Insomnia or Restlessness

Less common side effects include:

• Convulsions (Seizures) • Erectile Dysfunction • Depression

• Panic attacks • Fever • Hallucinations

• Tremors or shaking • Fainting • Overactive reflexes

I understand Phentermine treatments may involve these risks and other unknown risks. Initials:

I understand that use of Phentermine is absolutely contraindicated during pregnancy and breastfeeding. I understand that it is my responsibility to inform my physician if I am pregnant, if I am trying to become pregnant or if I become pregnant during the course of these treatments. Initials:

I agree to immediately report any problems that might occur to my medical provider during the treatment program. I further understand that not complying with the dosage recommendations and dietary restrictions could increase risks and alter my results from the program. If I do not follow these recommendations and restrictions, I agree to release the doctor and facility from any liability arising as a result of this. Initials:

I understand that I may quit the program at any time. While adverse side effects or complications are not expected, in the event that an illness does occur, I understand that I need to contact my physician immediately. If I experience an emergency situation, I understand that I need to go to an emergency facility. Initials:

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I understand that if there are any changes in my medical history or there are any changes in my medications or any other changes relevant to this procedure, I will advise my physician at that time.

I have read and fully understand the above terms. All my questions have been addressed to my satisfaction. I agree to release the doctor and the facility from any liability associated with this procedure. In the event a dispute arises over the outcome of the procedure, I consent solely to arbitration as a legal means of settlement.

Patient’s Name Printed:

Patient’s Name Signed:

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Weight Loss Program

Physical Medicine