New Patient Electronic Intake Form

Name *

First

Last

ACKNOWLEDGEMENTS *

I acknowledge that I must be seen in person for phentermine, also known by its brand name as Adipex. This form is a request to have a TELEHEALTH 1st visit appt and I will allow for 48-72 business hrs processing time to review my records.

For in-person appt, you may book online via http://www.elevationweightloss.setmore.com

If all possible, I'd prefer to receive my prescription/refill by:

receiving USPS mail prescription at my home address. $8 fee for flat-rate mail
picking-up in-person at Elevation Medical during provider hours. $10 processing & pick-up fee

Patient's Desired Mailing Address for Mail Prescriptions (We cannot ship to Ohio) *

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 *

Patient's 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?

Are you interested in semaglutide, known by its brand name as Ozempic or Wegovy for weight loss?

Yes, without B-12 and Lipotropic Injections (typically $265+ per month)
Yes, with B-12 and Lipotropic Injections (typically $340+ per month)
No

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 vitamins? If yes, please explain. *

Past Surgeries *

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

Do you or your family have medullary thyroid cancer or MEN (Type II)? *

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 unless absolutely necessary--------

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. *

Sign Here.

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 phentermine 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 phentermine use. Write "NO" for no consent. *

Sign Here

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. *

Sign Here

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 Weight Loss due to my excess weight or obesity. I have discussed the limited success I have had in losing weight by diet and exercise alone. I understand I will be prescribed medications. I understand I will need to change my diet , exercise frequency and behaviors to aid in my long-term weight reduction efforts. I understand that the management of my weight will require a lifelong effort, no matter what method of weight reduction I choose. I understand that no drug can provide a quick fix for the problem of weight reduction and management. I understand that the use of 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 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 is 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 has 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 understand that Sermorelin may cause pain and swelling at the injection site. I understand that, rarely, Sermorelin may cause flushing, dizziness, headache, sleepiness, nausea, vomiting, or hyperactivity. 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. 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.

STATEMENT OF INFORMED CONSENT FOR USE OF SEMAGLUTIDE AND/OR TIRZEPATIDE I have sought the medical services of Elevation Medical Weight Loss due to my excess weight or obesity. I have discussed the limited success I have had in losing weight by diet and exercise alone. I understand I will be prescribed medications. These medications may include semaglutide or tirzepatide. I understand I will need to change my diet, exercise frequency and behaviors to aid in my long-term weight reduction efforts. I understand that the management of my weight will require a lifelong effort, no matter what method of weight reduction I choose. I understand that no drug can provide a quick fix for the problem of weight reduction and management. 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, any history of stroke or cancer, multiple endocrine neoplasia Type II, or medullary thyroid carcinoma. 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 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. I understand that semaglutide is 94% similar to natural human glucagon-like peptide 1 (GLP-1). Tirzepatide is the first dual GIP/GLP-1 receptor co-agonist. Both compounds acts as a physiological regulator of appetite and thereby reducing food intake by reducing feelings of hunger and increasing feelings of fullness/satiety. For long term success the treatment needs to be combined with lifestyle changes including nutritional, exercise and behavioral habits. I understand that my use of semaglutide/tirzepatide may expose me to the risks of various conditions, including but not necessarily limited to low blood sugar (glucose ≤70 mg/dL), fast heart rate, sweating, shakiness, intense hunger, or confusion, nervousness, overstimulation, restlessness, dizziness, insomnia (inability to sleep), euphoria (sense of well-being), dysphoria (sense of unhappiness or depression), tremor, headache, dry mouth, diarrhea, constipation, other gastrointestinal disturbance, medication allergies, impotence, or changes in libido (sex drive). I further understand that my use of semaglutide/tirzepatide may expose me to the less probable but more serious risk of potential pancreatitis, cholelithiasis and cholecystitis (gallstone and gallbladder disease), thyroid disease, heart rate, and dehydration. I am encouraged to ask questions as concerns may arise. I should promptly bring any questions I have to the attention of a qualified provider. I understand that if I begin to experience any unusual or unexpected symptoms at any time after I begin using semaglutide/tirzepatide, I should immediately contact my doctor. Unusual symptoms may include, but are not limited to, shortness of breath, edema (swelling of hands, legs or feet, heart palpitations or tachycardia (rapid heartbeat), nervousness, restlessness, insomnia, tremor, rapid breathing or respiration, or inability to tolerate exercise or activity. I understand that I may seek help from another qualified physician or go to a hospital emergency room. I understand that I should use semaglutide/tirzepatide in the manner prescribed by the doctor and not provide this medication to any other person. I understand that I should not increase my dosage of semaglutide/tirzepatide or use it with any other drug or substance without the recommendation of my doctor . Serious injury or death can result from improper use of medications and/or the illegal transfer of medications to another individual. I understand that I may decline to begin treatment using semaglutide/tirzepatide. I also understand that I may stop using semaglutide/tirzepatide at any time in the future, but should notify my doctor before doing so. I recognize that it is safer to diet alone. I am requesting medication to help control my appetite. I assume responsibility for taking my diet pills and waive Elevation Medical Weight Loss of any liability. My health has been good and I will advise Elevation Medical Weight Loss should my health change. 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 semaglutide/tirzepatide 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.

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

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.

TELEHEALTH ONLY: I authorize consent for you to securely store my credit card information for future visits with my authorization to be charged a mutually-agreed upon service fees. **NOTE THAT ELEVATION MEDICAL SHALL NOT CHARGE YOUR CARD WITHOUT YOUR PERMISSION** *

Yes, please store my card information for future telehealth visits
No, please DO NOT store my credit card info.

Other/Comments/Suggestions/Notes to Us *

You type here. Type "no" if you do not have any comments.

TELEHEALTH ONLY: Name on Credit Card

First

Last

TELEHEALTH ONLY: Card Number

TELEHEALTH ONLY: Card Exp Date

TELEHEALTH ONLY: Credit Card CVV

Signature

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 unless I provided explicit authorization to securely store information above. 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. *

Please type any notes/comments,or explain any YES questions here. Also, please re-confirm your shipping address *

Please type any notes/comments,or explain any YES questions here. Also, please re-confirm your shipping address

Phone

updated 9/22/2020