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Weight Loss Form

Weight Loss Forminfo@flmmjhealth.com2024-08-18T12:06:13+00:00

"*" indicates required fields

Weight Loss Intake Form

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Medical History

Medical History
Please select any relevant conditions below:
Have you or a family member been diagnosed with either of the following?
Are you allergic to any of the following?
Do you have any other allergies?
Please list them
Are you currently taking any blood thinning drugs? (i.e., Aspirin and Warfarin)
Have you had surgery in the past year?
Medication History
Medication or supplements
Dose
Frequency
Comments
 

Female Medical History

Are you currently

Health Habits

Do you smoke?
Do you drink alcohol on a regular basis?
How is your activity level?
What methods or interventions have you used to lose weight previously?
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What factors do you consider contribute to your experience of excess weight?
By signing below, I acknowledge that I have provided complete and accurate information and understand that it will be used to assess my suitability for any treatment. I understand that it is my responsibility to inform the physician of any changes to my medical history or routine. I agree to waive all liabilities of the physician or Compassionate Healthcare for any injury or damages incurred due to misrepresentation of my health history.
Clear Signature
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Cancellation Policy

At Compassionate Healthcare, we strive to provide an exceptional standard of care. In order to achieve this, we kindly request your cooperation in adhering to our cancellation policy.

We understand that life can be unpredictable and unexpected circumstances may arise. However, we kindly ask that you provide us with at least 24 hours notice if you need to cancel or reschedule your appointment.

Cancellations made within 24 hours of the scheduled appointment time may be subject to $25 cancellation fee.

While we understand that unforeseen circumstances can occur, a missed appointment where no notice is given not only affects our ability to serve other clients but also results in lost time and resources.

We value your time as well as the time of our other clients. If you arrive more than 15 minutes late for your scheduled appointment, we may need to reschedule your session or shorten the treatment duration.

We truly appreciate your understanding and cooperation in honoring our cancellation policy toensure that each patient receives the attention and quality service they deserve.

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Consent Form

I give my consent to taking GLP-1 Injections as prescribed by my healthcare provider. Semaglutide & Trizepatide are human-based glucagon-like peptide-1 receptor agonists used to manage chronic weight and diabetes. I have been informed of the correct method of administering semaglutide injections and the dosage. I will not take this medication if I have a history of the following:
I give my consent

Possible side effects: nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dyspepsia, dizziness, abdominal distension, belching, hypoglycemia, flatulence, gastroenteritis, and gastroesophageal reflux disease. Common injection site reactions include itching, burning, and skin thickening (welting). In case of any serious allergic reaction, such as rash, itching, swelling of the face, tongue, or throat and anaphylaxis, seek immediate medical assistance.

Possible drug interactions: anti-diabetic agents, particularly Insulin and Sulfonylureas, can lead to an increased risk of hypoglycemia (low blood sugar). Additionally, do not combine with other GLP-1 agonist medicines (i.e., Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy®). Inform your provider of any medications that may lower blood sugar. I acknowledge that semaglutide is one part of a comprehensive lifestyle approach that includes a healthy diet and exercise, and regular follow-up visits to adjust dosages are necessary.

By signing below, I confirm that I have been fully informed of the potential risks, benefits, and complications and I voluntarily agree to taking this medication. I have had the opportunity to ask questions, and all my concerns have been addressed to my satisfaction. I release the prescribing physician and Compassionate Healthcare from any liability or claims arising from the treatment.

Clear Signature
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