Florida Medical Weight Loss Patient Forms

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Date:

MM slash DD slash YYYY

Home Phone:Cell Phone:

Birth date:

MM slash DD slash YYYY
Height: Weight: Race (ie. White, Asian, African American):

Occupation: How did you hear about us? Primary Care Physician: Phone:Emergency Contact: Phone:Relationship:

Health and Wellness History

Has your doctor advised you to lose weight?

Please explain: How often do you exercise? What type of exercise?

Please explain:

Please answer the following questions honestly so we can do our best to help you reach your goals.

What changed that caused the weight gain (if anything)? What’s the main reason you are seeking treatment at this time? What do you consider to be your ideal weight? When was the last time you were at your ideal weight? How much weight do you want to lose? How many times a year do you diet? What is the hardest part about managing your weight?

Please check all previous programs that you have tried in order to lose weight. Indicate dates and length of and any current medications:

Program

Have you maintained weight loss for up to a year with any of these programs? What did NOT work for you about these programs? What has been your lowest________and highest________weight as an adult? What has been your lowest What’s more important inches lost or pounds? What’s more important, fast or permanent? How fast do you want to be slim, trim and fit? What would stop you from a weight loss program?

What do you choose to eat between meals?

Briefly describe your daily eating behaviors:

What do you remember most about it?

List ALL medications & supplements you take (prescription & over the counter)

Please list all known DRUG and FOOD allergies:

Other:

Amount

PPD How many years?

AUTHORIZATION & NOTICE OF PRIVACY PRACTICES

I understand that my private healthcare information is protected under HIPPAA Privacy Regulations.

I fully understand that my signature is consent and authorization to be examined by the Center for Wellbeing medical team.
I understand that my entire patient history will remain completely confidential and will not be released without express written consent from me.Date

MM slash DD slash YYYY


I,Name authorize FLORIDA MEDICAL, INC. and the advanced practice clinician (s) and/or whomever may be designated as the medical assistant(s), to help me in my weightreduction efforts. I understand that my program may consist of a balanced deficit diet, a regular exercise program, instruction in behavioral modification techniques, and may involve the use of appetite suppressant medications, such as Semaglutide and Tirzepatide. Other treatment options may include a very low caloric diet, or a protein supplemented diet. It has been explained to me to my complete satisfaction that these medications have been used safely and successfully in private medical practices as well as in academic centers for periods exceeding those recommended in the medication product literature.I understand that any medical treatment may involve risks as well as the proposed benefits. I also understand that there are certain health risks associated with remaining overweight or obese. Risks associated with remaining overweight are tendencies to have high and increasing higher blood pressure, diabetes, heart attack and heart disease, arthritis of the joints including hips, knees, feet and back, sleep apnea, and sudden death. I understand that these risks may be modest if I am not significantly overweight, but will increase with additional weight gain.I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances made to me that the program will be successful. I also understand that obesity may be a chronic, life-long condition that may require drastic changes in eating habits and permanent changes in behavior to be treated successfully.Possible side effects from the weight loss drugs may include gastrointestinal discomfort, nausea, vomiting or changes in blood sugar levels.I have read and fully understand this consent form and “no show” policy. I have had all of my questions answered to my complete satisfaction. I have been given all the time that I need to carefully read and understand this form.

PRICING FOR MEDICATION

Please note that we do not take insurance for our weight loss program. Payment is due at the time of service. We would be happy to provide you will a receipt to send to your insurance company to try to get reimbursed.

Pricing is as follows:

Tirzepatide – $799 for a two month supply (including a weekly B12 ultra-burn fat booster)

Semaglutide – $659 for a two month supply (including a weekly B12 ultra-burn fat booster)

Patient Full Name: Date

MM slash DD slash YYYY