New Patient Information Form | Transformations Center for Weight Loss

(443) 356-0007

Patient Registration Form

First Name:

Last Name:

Date of Birth

Gender

Marital Status:

Address:

Email:

Phone:

Message:

Is this your first visit?

Yes

Current Weight (lbs)

Current Height (Inches)

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Patient Contact Information

Please provide your Emergency Contact and Primary Care Provider Information

Name of Emergency Contact:

Emergency Contact's Phone Number:

Your Relationship to Emergency Contact:

Do you have a Primary Care Provider?

Yes

Primary Care Provider:

Primary Care Provider's Phone Number:

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PREGNANCY

Women Only

Last Period:

Are you Pregnant?

Yes

Are you planning to get pregnant?

Yes

Are you nursing?

Yes

Birth Control Method:

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SOCIAL HISTORY

Do you use Tobacco Products?

Yes

How many packs a day?

Do you use any illicit drugs?

Yes

If Yes, please list type.

Have you used any illicit drug in the past?

Yes

If Yes, please list type.

Do you consume alcohol?

Yes

How much?

How often do you drink?

Daily

Few Times a Week

Few Times a Month

Social Drinker

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ALLERGIES

Reaction

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Medication History

Names of Medications

Dose

Frequency

How long have you been taking?

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Not currently taking any

HOSPITALIZATION AND SURGICAL HISTORY

HOSPITALIZATION AND SURGICAL HISTORY

Date of Surgery:

Type of Surgery

Outcome:

Date of Surgery:

Type of Surgery:

Outcome:

Date of Surgery:

Type of Surgery:

Outcome:

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None

Others

Opt-In

None of the Above

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EXERCISE HISTORY

Which of the following best describes you?

I used to exercise but have not recently.

I have never really liked exercise.

I am currently exercising on a regular basis.

Did you ever try to diet and lose weight in the past?

Yes

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Reference

How did you hear about us?

Who referred you?

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I acknowledge that all the information provided above is true and accurate to the best of my knowledge and will notify my provider of any changes in the future.

First Name:

Last Name:

Date:

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PATIENT TREATMENT CONSENT FORM

I, THE UNDERSIGNED PATIENT:

I have specifically requested, Transformations Center for Weight Loss (TCWL) health care providers be authorized to prescribe medication to help me lose weight. I will use the medication as prescribed and directed by TCWL health care provider(s) and I will not abuse this medication. I will notify TCWL health care provider(s) of any side effects from the medications immediately. In requesting TCWL health care provider(s) to provide me with medication to help me lose weight, I will discuss this with my primary care provider to help them manage my medication and health condition appropriately. I will notify TCWL health care provider(s) in case there are any changes in my medical condition including medications taken and any upcoming procedures or tests. If I do not, I agree not to hold TCWL health care provider(s) legally or medically responsible for the consequences that may arise from not doing so.TCWL will order baseline blood work and EKG prior to starting the weight loss program or if I have one done within the last six (6) months, email, fax or bring copies with me to the first appointment. I accept full responsibility for not getting the tests done and relieve TCWL health care provider(s), staff, and/or any of their affiliates from any and all medical and/or legal liability from any abnormality that might be missed by not ordering and performing these tests.

While I am on this medication, I WILL NOT DRINK ALCOHOL OR USE ANY ILLEGAL OR NONMEDICAL PRESCRIPTION DRUGS.

Depending on my progress, I authorize TCWL health care provider(s ) to keep me on the appetite suppressant medication shorter or longer than the recommended duration and more or less than the recommended dose based on the outcome of my weight loss. This will be based on my weight, goal, and medical needs and may change at any given time. I will not engage in obtaining prescription appetite suppressants illegally. I will not engage in obtaining prescription appetite suppressants for any other purpose but to lose weight. I will not receive appetite suppressants from any other health care providers while in the program. I do not intend to do so in the future as long as I am with this program. I have fully revealed any and all medical information as well as medicines that I am taking. Prescription appetite suppressants should not be taken by persons with a history of drug and/or alcohol abuse or dependence. Do not attempt to get pregnant while in the program, if you do get pregnant while on the medication, I will not hold TCWL health care provider(s) legally or medically liable for any health problem for me or my child. I will notify TCWL health care provider(s) or staff if I decided to stop or be discharged from the weight management program. Patients have the right to stop taking the medication at any time but continue with the weight management program using behavioral modification, exercise, and diet only.

I have read and understood all the information included in this patient consent form and all my questions have been answered by the TCWL health care provider(s) to the best of their knowledge.

I have been urged to take all the time I need in reading and understanding this form and in talking with my doctor and/or his staff regarding risks associated with the proposed treatment and regarding other treatments not involving the appetite suppressants.

First Name:

Last Name:

Date:

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PRIVACY POLICY

Transformations Center for Weight Loss, LLC.

Statement of Privacy Practices

Our office is dedicated to protecting the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensure that your health information is never compromised is a principle concept of our practice. We may, from time to time, amend our privacy policies and practices but will always inform you of any changes that might affect your rights.

Protecting Your Personal Healthcare Information

We use and disclose the information we collect from you only as allowed by the Health Insurance Probability and Accountability Act. This personal health information will never be otherwise given to anyone- even family members- without your written consent. You, of course, may give written authorization for us to disclose your information to anyone you choose, for any purpose.

Our offices and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality of your records is always protected. Our privacy policy and practices apply to all former, current, and future patients, so you can be confident that your protected health information will never be improperly disclosed or released.

Collecting Protected Health Information

We will only request personal information needed to provide our standard of quality care, implement payment activities, conduct normal practice operations, and comply with the law. This may include your name, address, telephone number(s), Social Security Number, employment data, medical history, health records, etc. We will retain full ownership of all documentation collected and reserves the right to duplicate it for treatment purposes. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law.

Disclosure of your Protected Health Information

As stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and governmental official under certain circumstances. We will not use your information for marketing purposes without your written consent. We may use and/or disclose your health information to communicate reminders about your appointments including utilizing phone auto dialers to remind you of missed consults, follow-up to your diet, renewals, etc., voicemail/answering machine messages, postcards, newsletters and special events.

Patient Rights

You have the right to request copies of your healthcare information; to request copies in various formats; and to request a list of instances in which we, or our business associates, have disclosed your protected information for used other than stated above. All such requests must be in writing. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services.

We thank you for being a patient at our office. Please let us know if you have any questions concerning your Privacy Rights and the protection of your Personal Health Information.

First Name:

Last Name:

Date:

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LIPOTROPIC (LIPO-B COMPLEX) INJECTION INFORMATION

1. Methionine is lipotropic, meaning that it assists in metabolizing fat. It is an essential amino acid and is an aid to two other amino acids, cysteine and taurine.

2. Inositol is a co-enzyme that is required for the proper metabolism of fats. Inositol metabolizes fats and cholesterol and aids in transporting fat in the bloodstream.

3. Choline is another co-enzyme that is required for the metabolism of fats (blend fats with water) and thus lead to transport of fats out of the liver.

4. B-complex vitamins included in this injection are riboflavin (B2), niacin (B3), pyridoxine (B6), and cyanocobalamin (B12). These vitamins are essential for converting calories from protein, carbs, and fats into energy.

This mixture for injection is called MIC B-Complex, so named after the first letters of the components (Methionine, Inositol, Choline, B-complex vitamins).

The standard dose is 1 - 2ml given into a deep muscle.

I have been informed of the following regarding the injection:

» While all components generally have no side effects, doses must be taken at regular intervals. The injections are only effective temporarily. As soon as the effect of these drugs wears out, the body starts returning to normal.

» Some redness, minor discomfort, small bruising and bleeding at the injection site may occur. This will usually dissipate in a minimal amount of time.

» Some people have experienced allergic reactions to the injections.

» Weight loss can be inconsistent from one week to the next. There can be no guarantees as to the timetable of a weight loss program.

» If any abnormal heart racing occurs, I will contact my medical provider immediately.

» I will inform my practitioner of any changes in my medical history, current medications, and/or any changes relevant to this procedure prior to any future treatments.

Read and Sign Below:

Prior to injections being administered, I have thoroughly read the Lipo-B patient information and fully understand the above information about the Lipo B-Complex injection. I further acknowledge that I am taking this injection at my own risk.

I relieve Transformations Center for Weight Loss` health care provider(s) and staff from any and all legal and medical liability from any side effect that may occur as a result of receiving the Lipo B-Complex injection.

I have read and understand all and have agreed to these statements.

First Name:

Last Name:

Date:

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APPOINTMENT

PLEASE NOTE!!!

KINDLY CALL 302-546-2131 OR 443-356-0007 TO SCHEDULE YOUR APPOINTMENT AFTER SUBMITTING YOUR FORM

THANK YOU!