Healthcare Weight-Loss Clinic Form

Healthcare Weight-Loss Clinic Form

Patient Information

Patient Name:

Date of Birth:    Gender: Female Male Other

Emergency Contact

Insurance Information

Medical & Surgical History

Anthropometrics & Weight History

Height:    Current Weight:    Highest Adult Weight:

Screening Questions

Are you currently pregnant? Yes No

Are you breastfeeding? Yes No

Do you use tobacco products? Yes No

History of cardiovascular disease? Yes No

Diabetes? Yes No

Treatment Options & Consent

I consent to participate in the clinic's medically supervised weight-loss program, which may include nutritional counseling, behavior modification, supervised meal plans, medication management (including prescription anti-obesity medications), subcutaneous injection therapies, and routine clinical monitoring. I understand that specific interventions will be discussed and documented in my individualized care plan.

Please indicate which interventions you consent to be considered as part of your treatment plan:

Nutrition counseling and meal planning
Behavioral therapy and lifestyle coaching
Prescription weight-loss medication management
Injection therapy (e.g., GLP-1 receptor agonists) as indicated
Laboratory testing, vital signs, and periodic monitoring

Risks, side effects, and potential complications vary by intervention and may include, but are not limited to: nausea, vomiting, gastrointestinal symptoms, hypoglycemia, injection site reactions, dehydration, nutrient deficiencies, changes in mood, increased heart rate, gallbladder disease, and rare but serious adverse events. Surgical options, if discussed, carry separate surgical risks. I acknowledge that not all risks can be listed here and that my clinician will explain risks specific to recommended therapies.

I understand the likely benefits include weight reduction, improved metabolic parameters, and reduced risk of obesity-related complications. No guarantee of specific weight loss or medical outcome is provided. I have the right to ask questions, request alternatives, and to withdraw consent at any time prior to receiving a treatment.

Authorization to Obtain and Release Medical Records

I authorize the clinic to obtain my relevant medical records and to release necessary information to other healthcare providers and my insurer for treatment, payment, and healthcare operations related to my weight-loss care. This authorization includes release of information regarding medications, laboratory results, and mental health or substance use history if relevant to treatment.

HIPAA & Privacy Acknowledgment

I acknowledge that the clinic has provided or offered a copy of its Notice of Privacy Practices describing how my protected health information may be used and disclosed. I understand my rights regarding my health information, including the right to request restrictions and the right to receive confidential communications.

I acknowledge receipt of the clinic's Notice of Privacy Practices.

Financial Responsibility & Appointment Policy

I understand that I am responsible for fees not covered by insurance, including consultation fees, medication costs, injection supplies, and laboratory testing. I authorize the clinic to bill my insurer when appropriate. I agree to the clinic's cancellation and no-show policy and acknowledge that repeated missed appointments may result in discharge from the program.

I accept financial responsibility as described above.

Patient Certification

By signing below, I certify that the information provided on this form is true and accurate to the best of my knowledge. I authorize clinicians to provide the recommended treatment(s) and to communicate with my other healthcare providers as needed for my care. I understand that I may revoke authorizations in writing, except to the extent actions have already been taken in reliance on my authorization.

Sign Now