Form

Home > Form

Please fill up the form before your Visit

Select Telehealth or Visiting our Clinic

Please fill all the forms for Telehealth

  • New Patient Form
  • Medical Weight Loss Consent Form
  • Telemedicine Consent Form

New Patient Form

1 / 3

    MEDICAL HISTORY

    Do you have the following Medical Conditions?

    Do you drink:

    DO YOU CRAVE?

    Emergency Contact

    The information provided is a true representation of my current health status and I will update my records if anything changes.

    Original Signature Only*

    Medical Weight Loss Consent Form

    2 / 3

      The information provided is a true representation of my current health status. I have read and understand and hereby agree to treatment administered to me, including medications for weightloss. I, the undersigned, have been informed by MED WEIGHTLOSS AZ CLINIC and its affiliates of the hazards and possible consequences involved in treatment by medications, supplements, injections and nonetheless consent to such treatment and agree to hold MED WEIGHTLOSS AZ CLINIC and its affiliates free and harmless of any claims, demands or suits for damage from any injury or complications whatsoever, save negligence, that may results in such treatment. I am also aware there is no guarantee for medication, treatment or results and understand patients may receive medications dispensed by a Nurse Practitioner.

      Original Signature Only*

      WE HAVE THE RIGHT TO REFUSE SERVICE(S)

      I agree to pay for all services rendered to me. Should you pursue a chargeback through your credit card company, or otherwise accrue an unpaid balance, you forfeit your right to privacy of the information required to pursue collection and/or legal action will be disclosed in seeking remuneration.

      Original Signature Only*

      I voluntarily consent to the above treatment and acknowledge the medications may be ordered under my name to be dispensed. I realize that neither the doctor nor any personnel of MED WEIGHTLOSS AZ CLINIC and its affiliates has made any absolute guarantees to me regarding cure or improvement of my condition. I understand that I am free to withdraw my consent and discontinue participation in these treatments at any time.

      Original Signature Only*

      IF I SUSPECT I COULD BE PREGNANT I UNDERSTAND I SHOULD DISCONTINUE ALL MEDICATIONS, SUPPLEMENTS, or INJECTIONS. PREGNANT OR NURSING MOTHERS SHOULD NOT BE TAKING APPETITE SUPPRESSANTS NOR GLP-1 MEDICATIONS.

      **MEDICAL DISCLAIMER:

      Pregnancy: weigh risk/ benefit during pregnancy; no human data available; possible risk of fetal harm, incl. teratogenicity and fetal death, base on animal data at

      Avoid pregnancy by using effective contraception during tx and for at least 2mo after D/C in female pts

      Lactation: weight risk/benefit while breastfeeding; no human data available, though risk of infant harm not expected based on drug properties; no human data available to assess effects on milk production

      By signing this document, I have read the above and consent for treatment.


      Telemedicine Consent Form

      3 / 3



        PURPOSE: The purpose of “Telemedicine Consent Form” is to get the patient’s consent in order to participate in appointments of telemedicine cares.

        RECORDS: Telecommunications with patients will not be recorded and stored. Patients’ medical information obtained by the diagnosis and analysis can be used anonymously for further improvements in scientific studies.

        TELEMEDICINE INFORMATION: The medical information related to history, records and tests of the patient will be discussed during the telemedicine appointment with video and audio.

        ACCESS: The patient accepts that he/she needs access to PC, laptop, or mobile device and a good internet connection in order to have an efficient telemedicine appointment.

        PATIENT RIGHTS: The patient can withdraw his/her consent at any time and can ask the questions related to telemedicine appointments and technical requirements for telecommunication.

        By signing this form,

        I understand that all the laws that are protecting my privacy of medical history or information are also applied to telemedicine practices.

        I understand that I can withdraw the consent at any time and at that point an in office visit will be required for future treatment; with controlled substances and/or medication adjustments.

        I accept that I authorize health care professionals and use telemedicine for my treatment and diagnosis and I agree to terms & conditions.

        Original Signature Only*

        New Patient Form

          MEDICAL HISTORY

          Do you have the following Medical Conditions?

          Do you drink:

          DO YOU CRAVE?

          Emergency Contact

          The information provided is a true representation of my current health status and I will update my records if anything changes.

          Original Signature Only*

          Telemedicine Consent Form



            PURPOSE: The purpose of “Telemedicine Consent Form” is to get the patient’s consent in order to participate in appointments of telemedicine cares.

            RECORDS: Telecommunications with patients will not be recorded and stored. Patients’ medical information obtained by the diagnosis and analysis can be used anonymously for further improvements in scientific studies.

            TELEMEDICINE INFORMATION: The medical information related to history, records and tests of the patient will be discussed during the telemedicine appointment with video and audio.

            ACCESS: The patient accepts that he/she needs access to PC, laptop, or mobile device and a good internet connection in order to have an efficient telemedicine appointment.

            PATIENT RIGHTS: The patient can withdraw his/her consent at any time and can ask the questions related to telemedicine appointments and technical requirements for telecommunication.

            By signing this form,

            I understand that all the laws that are protecting my privacy of medical history or information are also applied to telemedicine practices.

            I understand that I can withdraw the consent at any time and at that point an in office visit will be required for future treatment; with controlled substances and/or medication adjustments.

            I accept that I authorize health care professionals and use telemedicine for my treatment and diagnosis and I agree to terms & conditions.

            Original Signature Only*

            GLP 1 CONSENT FORMS

              Women of childbearing potential are encouraged to use contraception during SEMAGLUTIDE/TIRZEPATIDE (GLP-1) therapy; if pregnancy is desired, stop treatment at least 2 months prior to a planned pregnancy due to its long washout period. ALERT your provider IMMEDIATELY if you suspect that you are pregnant. Semaglutide/Tirzepatide could present a risk to the fetus.

              Original Signature Only*

              COMMON SIDE EFFECTS of GLP-1 Medications include: – Constipation, Diarrhea, Dyspepsia, Hypoglycemia, Injection site reaction, Nausea, Vomiting, Abdominal pain, Gastroesophageal reflux (GERD) Dizziness, Eructation, Fatigue, Headache, Anorexia. Not recommended for anyone with severe kidney or pancreas issues*, diabetic retinopathy nor patients with severe Gl disease (e.g., Crohn’s disease, gastroparesis, inflammatory bowel disease, ulcerative colitis) nor pregnant/breastfeeding. *GLP-1 Medications has rarely caused a very serious (possibly fatal) disease of the pancreas (pancreatitis)

              Original Signature Only*

              Get medical help right away if you develop symptoms of pancreatitis, including severe stomach/abdominal pain, nausea/vomiting that doesn’t stop. Semaglutide/Tirzepatide injection may increase the risk that you will develop tumors of the thyroid gland, including medullary thyroid carcinoma (MTC; a type of thyroid cancer). The risk increases if you have a personal or family History of MTC. Laboratory animals who were given Semaglutide/Tirzepatide developed tumors, but it is not known if this medication increases the risk of tumors in humans. Tell your provider if you or anyone in your family has or has ever had MTC or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2; condition that causes tumors in more than one gland in the body). If so, your doctor will probably tell you not to use Semaglutide/Tirzepatide injection.

              Original Signature Only*

              I recognize the potential risks and benefits of GLP-1 medications:

              Original Signature Only*

              I fully understand and accept responsibility for the situation that certain health risk and/or conditions might arise due to the contraindications of the use of GLP-1.

              Original Signature Only*

              Semaglutide/Tirzepatide is an Injectable medication. You will be provided with directions on how to administer the medication and agree that you are comfortable to self-administer medication before taking it home. MEDICATION CANNOT BE RETURNED.


              Get $50 Off on your First Medication