Weight Loss Concent – Verve Health

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Weight Loss Consent Form

Weight Loss Consent

"*" indicates required fields

Patient Information

First Name*

Last Name*

Email*

Date of Birth*

Address*

City*

State*

Zip Code*

Emergency Contact Name*

Emergency Contact Phone*

Occupation*

Preferred Language*

Race*

Driver’s License number*

Drivers License State*

Patient Vitals

Biological Sex*

Height*

Weight (lbs)*

Primary Care Provider*

Blood Pressure (Systolic)*

Blood Pressure (Diastolic)*

Last Bloodwork/Labs*

Last Phyical Exam*

Health History

Please list all medications/supplement dosages & frequencies of what you are currently taking*

Please list any allergies*

Please list all surgeries*

Personal Health History - Please check all that apply*

Family History - Does anyone in your family (living or deceased) have the following*

Do you Smoke?*

Yes

Do you Drink Alcohol?*

Yes

Do you use any Illicit Drugs?*

Yes

Are you sexually active?*

Yes

Smoking Type and Frequency*

Alcohol Type & Frequency*

Drug Type & Frequency*

Do you have a personal or family history of medullary thyroid carcinoma or MEN 2?*

Yes

Female Health History

Last Pap smear & any abnormal results*

Last Mammogram, any abnormal results?*

Number of pregnancies and live births*

Are you pregnant or trying to get pregnant?*

Yes

Contraceptive or barrier method(s) you are using*

Disclosures

HIPAA Consent*

I have read, understand, and consent to the above

Your right to privacy in this medical practice is paramount and we will never disclose any of your personal information without your express consent, unless required to do so by law. This notice describes our office’s policy for how medical information about you may be used and disclosed, how you can get access to this information, and how your privacy is being protected. Please read it carefully. The Physician will acquire private information about their patients. This is confidential and will not be discussed outside the office, except that the Physician may discuss patients with other healthcare professionals in terms that do not allow identification of the individual. Your protected health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment, or treatment. Your name, address, phone number, and your health care records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that may be of interest to you. If you are not home to receive an appointment reminder or other related information, a message may be left on your answering machine or with a person in your household. You have a right to confidential communications and to request restrictions relative to such contacts, or contact by alternative means. Additionally, we may be required to disclose your health information in the following circumstances: In the event of an emergency; if required by law; if there are substantial barriers to communicating with you, but in our professional judgement we believe that you intend for us to provide care; if ordered by the courts, government authorities, public health, law enforcement, coroners, or funeral directors; in the event of organ donations, research, military activity, or for national security.

Consent to Telehealth*

I have read, understand, and consent to the above

Telehealth involves the use of electronic communications to enable health care providers to provide patient care through the means of live two-way audio and/or video. The purpose of this form is to obtain your consent to participate in a Telehealth consultation for various medical conditions/illnesses. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following: Patient medical records, Medical images, Live two-way audio and/or video and Output data from medical devices and sound and video files. During the telehealth consultation: details of your medical history, examinations and tests will be discussed using interactive video and/or audio, a virtual examination may take place, other medical professional such as a medical assistant may be present during the visit to assist the provider, and photographs may be take during the service if needed and you consent. In an emergency, it is the responsibility of the Telehealth provider to direct the patient to emergency medical services, such as an emergency room. The Telehealth provider may also discuss and advise with the patient's local provider (if applicable). The Telehealth provider's responsibility will end upon the termination of the Telehealth connection.
Confidentiality
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and ensure its integrity against intentional or unintentional corruption. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the Telehealth consultation.
Possible Risks
As with any medical procedure, there are potential risks associated with the use of Telehealth. These risks include, but may not be limited to: In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the provider. There are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. The session may be discontinued by the patient and/or the provider if the video conference connection is not adequate for the situation.
Your Rights
You may withhold or withdraw consent to the Telehealth consultation at any time without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
Patient Consent"

Signature*

Date*

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