New and Returning Testosterone Patient Form

Name *

First

Last

Your Preference of 1st Visit *

Telehealth Video/Phone Appt (please allow for 24-48 business hrs processing time to review your records)
Regular IN-PERSON office appt (please allow for 24-48 business hrs processing time to review your records)

Please let us know if you prefer a telehealth visit or an in-office visit. For in-person appt, you may book online via http://www.elevationweightloss.setmore.com

Address *

Address Line 1

Address Line 2

City

State

Zip Code

PLEASE NOTE THAT WE DO NOT SEND YOU ANY MAIL UNLESS YOU PROVIDE POSTAL MAIL-COMMUNICATION CONSENT.

Phone *

Email *

Date of Birth (xx/xx/xxxx) *

Are you interested in getting help to lose weight? *

Have you tried diet and exercise? *

Have you taken any over-the-counter or prescription diet medications in the past? *

If yes, please list:

Did you experience any complications or side effects?

Do you know which weight loss program you are interested in? *

Females: When was your last menstrual period?

Females: Are you using contraception/preventing pregnancy?

Height *

Weight *

What's Your Goal Weight?

Current Blood Pressure *

Do you have a PCP/GYN? When was your last routine medical exam? *

Current Medications *

Drug Allergies *

Have you ever had any allergic or adverse reaction to vitmains or lidocaine? If yes, please explain. *

Past Surgeries *

Do you have heart disease or heart murmur? *

Do you have any history of passing out or syncope? *

Do you have a history of substance abuse? *

Do you have a high thyroid condition? (hyperthyroidism) *

Do you have glaucoma and/or Leber's Hereditary Optic Neuritis? *

Do you have any psychiatric or mental conditions? *

Do you have an eating disorder? *

Do you have a history of strokes? *

Do you have a seizure disorder? *

Do you have ADHD? *

Are you interested in Botox or Fillers?

Yes, Botox and/or Fillers
No

Please email hello@elevationweightloss.com for more information.

Consent to electronic communications: *

I give permission to my provider to contact me through text-messages, phone calls, and by email. I agree to the terms of use in consenting for electronic communications.
I'd prefer an in-office visit and will be booking by calling the office phone or http://www.elevationweightloss.setmore.com
------DO NOT TEXT or EMAIL ME--------

I have read and understand the consent form. I have agreed to submit this information by electronic means. I am electronically signing this form and verifying all information I have provided is true. Write "NO" for no consent. *

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Please type any additional comments or explain any yes questions here:

I have read and understand the statement of informed consent for the use of electronic communications and acknowledge that I will have opportunities to ask questions during my telehealth visit. I am signing my FULL NAME below to allow consent for electronic communication. Write "NO" for no consent. *

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I have read and understand the statement of informed consent for the use of sermorelin and acknowledge that I will have opportunities to ask questions during my telehealth visit. I am signing my FULL NAME below to allow consent for sermorelin use. Write "NO" for no consent. *

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I have read and understand the statement of informed consent for the use of Vitamin B-12/Fat Burner Lipotropic/Vitamin-C injections and acknowledge that I will have opportunities to ask questions during my telehealth visit. I am signing my FULL NAME below to allow consent for B-12/Fat Burner Lipotropic/Vitamin-C injections use. Write "NO" for no consent. *

Sign Here. Write "NO" for no consent to B12/Fat Burner/Vitamin-C injections.

Consents are valid when you have decided to pursue the weight loss option. Payment is due at the time services are rendered. According to FDA Policy Sec. 460.300, I acknowledge that I cannot return or receive refunds for medications and/or injections once the medications/injections leave the office regardless of effectiveness or possible adverse reactions. All service fees paid are FINAL. *

I Agree
I Disagree

STATEMENT OF INFORMED CONSENT FOR USE OF SERMORELIN: I have sought the medical services of Elevation Medical to improve my overall well-being. I have discussed the limited success I have had by changing my lifestyle and habits. I understand I will be prescribed medications. These medications may include testosterone injections, B-12 and or lipotropic injectiosn, and Sermorelin (a medication that promotes the secretion of human growth hormone). I understand I will need to change my diet , exercise frequency and behaviors to aid in my long-term health improvement efforts. I understand that the management of my health will require a lifelong effort, no matter what method of treatment I choose. I understand that no medications can provide a quick fix for the problems of certain lifestyle. I understand that the use of testosterone and/or sermorelin in a manner differing from that recommended by the manufacturers and approved by the FDA has not been studied systematically or comprehensively. The safety and effectiveness of using testosterone and/or sermorelin in a manner differing from that recommended by the manufacturers and the FDA is unknown. I understand that one who is overweight or obese has a heightened risk of suffering from high blood pressure, heart disease, diabetes, heart attack, stroke and arthritis (particularly involving the hips, knees and feet) Depression is more common in obese persons than in others. I understand that the risks of incurring these conditions tend to increase as one’s obesity increases. Prior to my treatment, I have fully disclosed any medical conditions or diseases such as pregnancy, trying to get pregnant, breastfeeding, history of gallbladder disease, diabetes, autoimmune diseases, HIV, heart disease, liver disease, kidney disease, uncontrolled high blood pressure, seizure disorders, blood disorders, anemia, thalassemia, hemophilia, etc), emphysema or asthma, and any history of stroke or cancer. These contraindications have been fully discussed with me. If I fail to disclose any medical condition that I have, I release the physician and facility from any liability associated with this treatment. I recognize that it is safer to diet alone . I am requesting medications to assist me in my weight loss goals. I assume responsibility for taking my medications and waive Elevation Medical Weight Loss of any liability. My health has been good. I will advise Elevation Medical Weight Loss should my health change. I understand that Sermorelin are not FDA approved for weight loss and this application may be considered as “off-label use”. I understand there is no medical evidence to support the use of Sermorelin for this purpose. I further understand that Sermorelin have not been approved by the FDA as safe and effective in the treatment of obesity or weight control. There is no substantial evidence that Sermorelin increases weight loss beyond that resulting from caloric restriction, that it causes a more attractive or “normal” distribution of fat, or that it decreases the hunger and discomfort associated with calorie-restrictive diets. I agree to notify Elevation immediately if the following rare side effects occur: trouble swallowing, chest tightening, or vomiting. I further understand that allergies to Sermorelin are very unlikely, but can include rash, swelling, trouble breathing, and dizziness. I understand that I may stop this program at any time. While adverse side effects or complications are not expected, in the event an illness does occur, I understand that I need to contact Elevation Medical Weight Loss, inc. immediately. If I experience an emergency situation, I understand that I need to go to the emergency room. I understand the risks set forth above to my satisfaction. I have had an opportunity to ask questions I have concerning these and any other potential risks. I am encouraged to ask questions as concerns may arise. I should promptly bring any questions I have to the attention of a qualified physician. I have read and understand this consent form. I have had the opportunity to ask questions concerning this consent form and the medications to be prescribed for me. Any questions I have asked have been answered to my satisfaction. I understand that I should not sign this consent form unless I understand its contents, as well as the risks and benefits associated with the treatment proposed by Elevation Medical Weight Loss. I agree to release the physician and facility from any liability associated with Sermorelin treatment. In the event a dispute arises over the outcome of this treatment, I consent solely to arbitration as a legal means of settlement. Payment is due at the time services are rendered. According to FDA Policy Sec. 460.300, I acknowledge that I cannot return or receive refunds for medications and/or injections once the medications/injections leave the office regardless of effectiveness or possible adverse reactions. All service fees paid are FINAL. Write "NO" for no consent. *

Sign Here

Vitamin B-12 Injection Consent Form: I am requesting a B-vitamin/amino acid injection in the muscle. This injection may also contain any of the Vitamin B, Methionine, Inositol, Choline, L-Carnitine, or other amino acids. I understand that I am receiving a nutrient/vitamin injection. Most side effects are mild or moderate in nature, and their duration is short lasting (several hours, but very rarely up to 5 days). The most common side effects include, but are not limited to, temporary injection site reactions like: pain/tenderness, firmness, redness, swelling, bruising, swelling, lumps/bumps, itching, discoloration, and tingling. As with all injections, there are risks such as infection, scarring, skin atrophy, and neuropathy. I agree to release Elevation Medical Weight Loss and the medical practitioner from any liability arising from injection therapy. Payment is due at the time services are rendered. According to FDA Policy Sec. 460.300, I acknowledge that I cannot return or receive refunds for medications and/or injections once the medications/injections leave the office regardless of effectiveness or possible adverse reactions. All service fees paid are FINAL. Write "NO" for no consent. *

Sign Here. Write "NO" for no consent.

CONSENT TO OPT-IN to EMAIL/TEXT/VIDEO COMMUNICATION: I acknowledge that the transmission of my personal information by email, phone, texting and/or video conferencing has a number of risks. These include, but are not limited to, the following risks: Emails, phone calls/voicemails, and text messages can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients. Email and text senders can easily misaddress an email or text and send the information to an undesired recipient. Backup copies of emails and texts may exist even after the sender and/or the recipient has deleted his or her copy. Employers and on-line services have a right to inspect emails sent through their company systems. Emails, phone calls, voicemails, and texts can be intercepted, altered, forwarded or used without authorization or detection. Emails, voicemails, and texts can be used as evidence in court. Emails, phone calls, voicemails, and texts may not be secure and therefore it is possible that the confidentiality of such communications may be breached by a third party Conditions for the use of email and texts: The provider cannot guarantee but will use reasonable means to maintain the security and confidentiality of email, phone, voicemail, and text information sent and received. The provider is not liable for improper disclosure of confidential information that is not caused by the provider’s intentional misconduct. Clients/Parent’s/Legal Guardians must acknowledge and consent to the following conditions: The provider cannot guarantee that any particular email and/or text will be read and responded to within any particular period of time. The provider will respond to text messages, voicemails, and emails Monday-Thursday during the hours of 9AM-5PM, unless otherwise specified. Voicemails, text messages, and emails will not be answered outside of these hours or on the weekends/holidays. Email and texting is not appropriate for urgent or emergency situations. If you experience a mental health emergency, please go to your nearest emergency room and/or call 911. Email and texts should be concise. The client/parent/legal guardian should call and/or schedule an appointment to discuss complex and/or sensitive situations. Email communication will usually be printed and filed into the client’s medical record. Texts may be printed and filed as well. Clients/parents/legal guardians should not use email or texts for communication of sensitive medical information. The provider is not liable for breaches of confidentiality caused by the client or any third party. It is the client’s/parent’s/legal guardian’s responsibility to follow up and/or schedule an appointment if warranted. Non-face-to-face evaluation and management of services provided by the provider to a client via telephone is subject to billing if initiated by an established client, or guardian of an established client. Client Acknowledgement and Agreement I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of cell phones, email and/or texts between my provider and me, and consent to the conditions and instructions outlined, as well as any other instructions that my provider may impose to communicate with me by email or text. By signing this form, I authorize the provider to send text messages to my cell phone regarding scheduling and treatment. I understand that standard text messaging rates will apply to any messages received. I also understand that I or the provider may revoke this permission in writing at any time. I agree not to hold the provider liable for any electronic messaging. The practitioner will take reasonable steps to ensure that all information shared through email is kept private and confidential. However, Elevation Medical Weight Loss, is not liable for improper disclosure of confidential information that is not a result of our negligence or misconduct. Patient information is protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320 et seq. 45 C.F.R. Parts 160 & 164, and the Confidentiality Law, 42 U.S.C. 290dd-2, 42 C.F.R. Part 2 Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate any alcohol or drug abuse. INFORMED CONSENT If you consent to the use of email/text messaging, you are responsible for informing your practitioner of any type of information that you do not want sent to you by email/text message other than the information detailed in Section B. You are responsible for protecting your password and access to your email account/ mobile phone and any email/text message you send or you receive from Elevation Medical Weight Loss to ensure your confidentiality. Your practitioner cannot be held liable if there is a breach of confidentiality caused by a breach in your account security. Any email/text message that you send that discussed your diagnosis or treatment constitutes informed consent to the information being transmitted. If you wish to discontinue email/text correspondence, you must submit written consent informing your practitioner that you are withdrawing consent to email/text correspondence. Write "NO" for no consent. *

Sign Here. Write "NO" for no consent.

Upload Valid PHOTO ID Here

Click or drag a file to this area to upload.

If you cannot do this you may email your valid PHOTO ID to: hello@elevationweightloss.com

Are you interested in Botox or Dermal Fillers? if yes, please email drcooper@elevationweightloss.com or call us 412-458-5042 to book a consult

if yes, please email drcooper@elevationweightloss.com or call us 412-458-5042 to book a consult

By checking this box, I acknowledge that my consult may take 48 business hrs to process and our provider may not be able to schedule me for a consult until 14 business days after I submit my New Patient Form. I understand and accept. *

By checking this box, I acknowledge that my consult may take 48 business hrs to process and our provider may not be able to schedule me for a consult until 14 business days after I submit my New Patient Form. I understand and accept.
By checking this box, I acknowledge that my consult may take 48 business hrs to process and our provider may not be able to schedule me for a consult until 14 business days after I submit my New Patient Form. I understand and accept.

Name on Credit Card

Billing Address

Address Line 1

Address Line 2

City

State

Zip Code

Credit Card Number

Credit Card Expiration Date

Credit Card CVV

Payment Authorization Form: I understand that my credit card/payment number on this form will be destroyed after payment is processed and that no payment information is stored. Elevation Medical will reach out to me either by email or text messages at the email or number I submitted to schedule a telephone health consult. I agree to allow for 72 business hours to fulfill my mail order requests and my order should be delivered within 7-10 business days. I acknowledge that I will receive a confirmation of payment and USPS tracking number by email at the email address I provided. I understand that there may be potential delays in receiving mail, and the delay may be up to 2 weeks. I understand that if I opt for the package to be sent without a signature required for drop-off, I accept all responsibility and liability, and may not hold Elevation Medical Weight Loss liable for lost or damaged packages. *

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