Intake - Hormone Fitness
Intake Forms
November 15, 2024 04:02 AM
General Information
Full Name
Test Test
Date of Birth
03/08/1992
Phone Number
(332) 413-2133
Email Address
testing@gmail.com
Gender (assigned at birth):
Male
Mailing Address
111 E , 332
Scottsdale, Arkansas, 74738
Height -> feet
5
Height -> inches
8
Total Height (in)
68
Current weight:
210
Your Current BMI is
31.93
Medical Information
Family Medical History:
(Throid cancer or
Multiple Endocrine)
Both
Medical Conditions:
None
Are you currently taking any medications?
YES
Please list all medications your currently taking:
medications
Do you have any medication allergies?
YES
Please list all medications allergies:
allergies
Have you had any h
ospitalizations or
surgeries?
Do you have a hypersensitivity to Semaglutide?
YES
Are you currently taking insulin or other insulin-releasing medications?
YES
Emergency Contact (required)
Relation to you
Guardian
Full Name
Jane Smith
Phone Number:
(342) 394-8323
Email Address:
smith@aol.com
Primary Care Provider (optional)
Your Provider
Dr. John
Phone (Office)
(394) 803-2922
PCP Address
100 E offfice, unit 1
Tempe, Idaho, 34023
A Warm Welcome to Hormone Fitness!
Would you like to set a "Goal Weight" for your GLP-1 treatments?
YES
Great! Please set your goal weight:
180
Your Goal BMI is
27.37
Are you interested in, or already planning, making any lifestyle changes while on GLP-1s?
YES
Good for you! Select all that apply:
Exercise routine
Current Weight
Goal Weight
180
210
Your Goal BMI is
27.37
Your Current BMI is
31.93
Patient Consent
Accepted
I authorize Boutique Medicine PLLC and any of its employed or contracted providers, including but not limited to physicians, nurse practitioners, physician assistants, nurses, and other healthcare personnel, to provide medical evaluations, treatments, and procedures that are considered medically necessary or advisable to diagnose and treat my health conditions. Below you will find important information regarding professional services provided by Boutique Medicine: Pharmaceutical based Medical Intervention | Nutritional Consult | Lifestyle Counseling. If I have any questions regarding the information below I will ask one of our staff to clarify. I understand my treatment may involve, but is not necessarily limited to, the use of weight management medications. I understand, the Semaglutide program is $375 and then $475 once the fourth and fifth titration is reached between 1.5mg and 2.5mg. I understand that Tirzepatide is $375 for 2.5mg dose, $425 for the 5mg dose, $495 for the 7.5mg dose, $575 for the 10mg dose, $600 for the 12.5mg dose and $675 for the 15mg dose when titrating up. I understand that maintenance program pricing will be as communicated to me at the time of the required doctor follow up visit. I understand that the initial doctor visit will be a $95 charge in order to get prescribed medication. Any additional visits with a doctor or initial visits for returning patients will be a $75 charge, including the required follow up doctor visit to get prescribed on the maintenance program. Returning patients are required to meet with a physician upon returning, if they have been off Semaglutide or Tirzepatide for more than 2 weeks. Our team of nurses and MA's are available to answer any questions or concerns you may have. They will also conduct recurring 4 to 6-week follow ups with you in order to prepare subsequent refills for patients. I understand that if I do not respond to the refill follow up requests within 48 hours, my refill will automatically be submitted at the current dose. I understand that Boutique Medicine PLLC (DBA Hormone Fitness) does not accept insurance and receiving reimbursement from my health insurance company for doctor visits, lab work, prescriptions or program fees is my responsibility. I understand that the cost of lab work is NOT included with any program. I understand that if I have an urgent medical condition, and I am unable to reach a doctor at Hormone Fitness directly, it is my responsibility to seek appropriate medical care. I further understand that if there is a medical emergency or serious medical concern, I am to call 911 immediately. I authorize and give consent for the physicians or medical staff to administer treatment and perform such procedures such as Weight Loss, General Health Care, and other services. I understand that the doctors intend to provide top quality care. However, if I am unhappy with any services I intend to immediately inform the staff at Hormone Fitness, so that my concerns/complaints can be addressed immediately. I believe I have enough information to make an informed decision and I agree to have the procedure.
Accepted
I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my written permission (i.e. medical release). We understand that information about you, your health, and your healthcare is personal. We are committed to protecting your personal health information (PHI). We request that you sign this form acknowledging that you have been given the opportunity to read and receive a copy of our policy regarding the confidentiality of patient medical records. This acknowledgment will be filed within your medical records.
Accepted
Prescription refill requests must be made 14 days prior to running out of medication, also please allow up to 7-10 business days for the refill to be processed, compounded and shipped. I understand that once a medication has been shipped it can not be returned or refunded. Refills will only be approved if your follow-up visits have been kept per your provider's recommendation. Prescriptions will only be handled during business hours.
Accepted
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.
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.
Accepted
Hormone Fitness is not prescribing the Brand name medication, such as Wegovy or Zepbound, BUT we are prescribing the generic compounded (Semaglutide or Tirzepatide) injection which is an injectable prescription medicine used for adults with obesity (BMI 30+) or overweight (excess weight) (BMI 27+) with a coexisting condition (PCOS, hypertension, hypercholesterolemia, prediabetes). Semaglutide should be used with a reduced calorie meal plan and increased physical activity. Semaglutide contains semaglutide and should not be used with other semaglutide-containing products or other GLP-1 receptor agonist medicines. Tirzepatide contains Tirzepatide and should not be used with other tirzepatide-containing products or other GLP-1 or GIP receptor agonist medicines. Uncommon side effects of Semaglutide and Tirzepatide Include: Pancreatitis. Stop using Semaglutide or Tirzepatide and call your healthcare provider right away if you have severe pain in your stomach area (abdomen) that will not go away, with or without vomiting. You may feel the pain from your abdomen to your back. Blurry Vision. Call your healthcare provider or seek medical attention if you have symptoms of blurry vision. If Blurry Vision occurs upon taking the medication, a doctor’s release will be required to continue treatment. Gallbladder problems. Semaglutide and Tirzepatide may cause gallbladder problems, including gallstones. Call your healthcare provider or seek medical attention if you have symptoms, such as pain in your upper stomach (abdomen), fever, yellowing of the skin or eyes (jaundice), or clay-colored stools. Serious allergic reactions. Stop using Semaglutide or Tirzepatide and get medical help right away, if you have any symptoms of a serious allergic reaction, including swelling of your face, lips, tongue, or throat; problems breathing or swallowing; severe rash or itching; fainting or feeling dizzy; or very rapid heartbeat. Increased heart rate. Semaglutide and Tirzepatide can increase your heart rate while you are at rest. Tell your healthcare provider if you feel your heart racing or pounding in your chest and it lasts for several minutes. Depression or thoughts of suicide. You should pay attention to any mental changes, especially sudden changes in your mood, behaviors, thoughts, or feelings. Call your healthcare provider right away if you have any mental changes that are new, worse or worry you. The most common side effects of Semaglutide and Tirzepatide may include: nausea, diarrhea, vomiting, constipation, stomach (abdomen) pain, headache, tiredness (fatigue), upset stomach, dizziness, feeling bloated, belching, gas, stomach flu and heartburn. It is better to take medication at night. The risks of the procedure have been explained to me. In addition, the procedure may not have the result that I expect. I understand that in addition to the risks described to me about this procedure there are risks that may occur with any medical procedure. I am aware that the practice of medicine is not an exact science, and that I have not been given any guarantees about the results of this procedure.
The risks of the treatment have been explained to me. In addition, the treatment may not have the result that I expect. I understand that in addition to the risks described to me about this treatment there are risks that may occur with any medical treatment. I am aware that the practice of medicine is not an exact science, and that I have not been given any guarantees about the results of this treatment.
Accepted
Appointment Cancellation's:
Due to high demand for the doctor's time, patients are on a waiting list. We ask you to please respect their time and other patient's time. We understand you may need to cancel, but please do so within 24 hours of your appointment in order to ensure we have time to fill your time slot with another patient. A $75 fee will be assessed to your account in the following scenarios: a) if you cancel your appointment with the doctor less than 24 hours before it is scheduled to take place, b) if you no-show your appointment with the doctor, c) if you are deemed a candidate for our program after you have met with the doctor, but decide to not proceed with our program. To avoid incurring these fees, please make note of your appointment date and time and contact us at least 24 hours prior to your appointment to cancel. You are welcome to cancel your membership at any time with no obligation unless your prescription has been sent to the pharmacy. Once your prescription has been sent to the pharmacy you are obligated to pay for that medication. Please, see more details in the Membership Cancellation Policy.
Membership Cancellation's:
Monthly Flat Rate Explanation: We charge our members a consistent monthly flat rate for our service. Depending on the strength of the medication prescribed, a single vial may provide anywhere from 4 to 10 weeks of medication. In an effort to make costs more predictable and affordable for our members, we have averaged out the cost across these variations. This method ensures that members are not overburdened due to fluctuations in their medication's duration. Cancellation Timeframe: Members wishing to cancel their subscription must notify us at least 2 weeks prior to their next billing cycle. This allows us adequate time to halt any scheduled refills tied to the member's account. Late Cancellation Penalty: Any cancellations made less than 2 weeks before the upcoming billing cycle date will result in the member being responsible for the cost of the last scheduled shipment. This penalty applies if we are unable to cancel the refill schedule in time due to late notification. Contact Information for Cancellations: To initiate the cancellation process, please contact us via email at info@hormonefitness.com. Ensure that you provide your full name, DOB, and a brief reason for cancellation to expedite the process.
Acknowledgment of Policy: By signing below, the member acknowledges they have read, understood, and agree to the terms and conditions of this Membership Cancellation Policy.
Your Signature
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