Patient Intake & Consent Forms

Patient Registration & Financial Responsibility

Name

Mr.

Mrs.

Miss

Other

First Name

Last Name

Current Gender Identity:

Date of Birth

Preferred Pronoun(s):

Age:

Sex Assigned at Birth:

Male

Female

Marital Status

Single

Partnered

Married

Widowed

Divorced

Separated

Home Address

City

State

Zip

Primary Phone Number

Secondary Phone Number

Email Address

Pharmacy Information

Preferred Pharmacy

Pharmacy Phone

Preferred Method of Contact (please check one):

Text

Phone

Emergency Contact Information (Optional):

Name

Relationship:

Phone Number

Medical Records Authorization

I authorize the release of any medical information to my Primary Care Physician (PCP) and any other healthcare providers involved in my care.

I do not authorize Charlotte Weight Loss and Wellness Clinic to release my medical records.

Weight & Medical History

Current Measurements (If unavailable, use last recorded vitals.)

Height: ___ ft ___ in

Weight__lbs

Blood Pressure:__/__

Heart Rate: ___ bpm

Weight Medical History

Weight History (Estimate as closely as possible.)

Life Event

Age:

Weight__lbs

Lowest weight in past five years:

Highest weight in past five years:

Goal Weight: __ lbs:

Do you use a home scale?

Yes

If yes, how often?

Bariatric Surgery?

Procedure:

Lap-Band

Gastric Bypass

Gastric Sleeve

Procedure Date

Motivation for seeking weight loss intervention:

Social History

Tobacco Use?

Yes

Do You Vape?

Yes

If yes, type and frequency:

Alcohol Use?

Yes

If yes, type, amount, and frequency:

Recreational drug use?

Yes

If yes, type and frequency:

History of drug overdose?

Yes

If yes, when?

Personal Medical History

Do you have any of the following? (Check all that apply):

Depression

Panic Attacks

Anxiety

Bipolar Disorder

Eating Disorder

OCD

Other

Are you currently receiving treatment for mental health condition?

Yes

Do you take medications for mental health conditions? (List under medications section.)

Yes

History of suicide attempt or suicidal ideation?

Yes

If yes, when?

Are you currently seeing a psychologist/psychiatrist/therapist?

Yes

Sleep Health

How many hours do you typically sleep per night?

Do you have insomnia (trouble falling or staying asleep)?

Yes

Has anyone told you that you snore loudly or stop breathing during sleep?

Yes

Do you experience excessive daytime sleepiness?

Yes

Have you been diagnosed with Sleep Apnea?

Yes

If yes, are you on CPAP or another oral device?

Yes

Cardiovascular Health

High blood pressure? (If yes, list medication under medications section.)

Yes

Heart attack?

Yes

If yes, when?

Heart bypass surgery?

Yes

If yes, when?

Stents?

Yes

If yes, when?

Pacemaker?

Yes

If yes, when?

Medical History

Endocrine & Metabolic Health

Diabetes?

Yes

If yes, do you have low blood sugar episodes?

Yes

Current A1C (if known):

Thyroid problems? (If yes, list medication under medications section.)

Yes

Gastrointestinal Health

Heartburn?

Yes

How often per week?

Do you experience upper abdominal pain after eating or at night?

Yes

Have you been diagnosed with gallstones?

Yes

Have you been diagnosed with fatty liver?

Yes

Respiratory Health

Do you have asthma?

Yes

Do you have COPD/Emphysema? (If yes, list medication under medications section.)

Yes

How far can you walk before getting short of breath?

Musculoskeletal Health

Do you have joint pain?

Yes

If yes, where?

Do you take medications for joint pain? (List under medications section.)

Yes

Have you seen an Orthopedic MD for joint pain?

Yes

Have you had surgery for joint pain?

Yes

If yes, list details below.

Are you waiting for a joint replacement until you lose weight?

Yes

Gynecologic & Obstetric Health

Age at onset of periods:

Menstrual Frequency & Duration:

Pregnancies:

Births:

Miscarriages:

Prolonged or abnormal bleeding?

Yes

If yes, describe below.

Medications (Include vitamins & supplements. Attach list if needed.)

I do not currently take any medications

Medication Dosage Frequency Comments (List)

Family & Weight Loss History

Family history of obesity?

Yes

If yes, list family members affected:

Medical conditions in immediate family?

Yes

If yes, list below:

Condition/Illness:

Family Member(s) Affected:

Food Intake & Dietary Habits

Current diet plan (if any):

Meals per day:

Do you skip meals?

Yes

Number of snacks per day:

Do you eat breakfast?

Yes

Time of dinner:

Typical bedtime:

Do you snack after dinner?

Yes

Do you snack between meals?

Yes

If yes, what and how often?

Dietary Restrictions

Vegetarian?

Yes

Gluten-Free?

Yes

Other:

Daily protein intake (drinks/food): __ g

Water intake (per 24 hours):

24oz

32oz

64oz

Other

Other beverages & quantity:

Serious Drug Interactions

Recreational drugs (e.g., cocaine, amphetamines, opioids) can cause life-threatening reactions with weight loss medications.

I have read, understand, and agree to this disclaimer.

Patient Initials:

Date

HIPAA & Privacy Acknowledgment

By signing below, I consent to the use of my protected health information for treatment, payment, and healthcare operations.

Digital Signature

Use your mouse or finger to sign in the box below.

Date

Photo Release Consent for Social Media & Marketing

Charlotte Weight Loss and Wellness Clinic loves to celebrate patient success! We request your permission to use before and after photos for educational and promotional purposes on our website, social media, and marketing materials.

Yes, I consent to the use of my before and after photos for marketing and promotional purposes.

No, I do not consent to the use of my photos.

Patient Initials:

Date

Informed Consent: Semaglutide & Tirzepatide for Weight Loss

How These Medications Work:

- Semaglutide (GLP-1 Receptor Agonist)

- Reduces appetite by slowing gastric emptying and increasing satiety.

- Helps regulate blood sugar and insulin production.

- Tirzepatide (Dual GIP & GLP-1 Receptor Agonist)

- Acts on two receptors for enhanced appetite suppression and glucose control.

Possible Side Effects: (Initial to Acknowledge)

Abdominal pain

Constipation

Dizziness

Nausea

Vomiting

Injection Site Reaction

Mood Changes

Hair Loss

GERD

Gallbladder Pain

Exclusions from GLP-1 Weight Loss Program

Patients with the following conditions CANNOT participate:

Medullary Thyroid Cancer

Pancreatitis

Multiple Endocrine Neoplasia

Gastroparesis

I confirm that, to my knowledge, I do not have any of these conditions.

Initials:

Warnings & Precautions

Enter your parEffects on Birth Control & Pregnancy

- Birth Control: GLP-1 medications may reduce the effectiveness of oral contraceptives, including birth control pills and injections. Patients should consider non-oral alternatives such as an IUD, implant, or barrier methods while on the GLP-1 Weight Loss Program.

Pregnancy

- Patients who are pregnant, planning to conceive, or actively trying should discontinue GLP-1 medications immediately.

- GLP-1 medications have not been extensively studied in pregnant women, but animal studies suggest potential risks such as reduced embryo size, developmental abnormalities, and fetal harm.

- If pregnancy occurs while taking GLP-1 medications, stop use immediately and consult a healthcare provider.

Anesthesia & Surgery Precautions

- Patients undergoing surgery requiring anesthesia must stop GLP-1 medications 7-14 days before surgery to reduce the risk of aspiration (stomach contents entering the lungs).

- Patients should inform their surgeon and anesthesiologist about their use of GLP-1 medications before surgery.

- GLP-1 medications delay stomach emptying, which may affect post-surgical recovery, especially for gastrointestinal procedures.

- Additional precautions may be required depending on the type of surgery.agraph text here...

Patient Acknowledgment

I acknowledge that I have read and understand the risks associated with GLP-1 medications and their effects on birth control, pregnancy, and anesthesia.-

I agree to inform my healthcare provider if I become pregnant or schedule a surgical procedure while taking GLP-1 medications.

Patient Initials:

Date

Charlotte Weight Loss and Wellness Clinic Disclaimer

Results vary by individual. Weight loss depends on lifestyle changes, medication compliance, and medical conditions.

No guarantees are made regarding weight loss outcomes.

Self-Pay Policy: I understand that all services are self-pay, and no insurance will be billed for consultations or weight loss treatments.

Refund Policy: All payments are final for consultations, programs, and treatments.

Medical Monitoring Required: I agree to scheduled follow-ups to ensure safety and effectiveness.

Consent to Participate in the Charlotte Weight Loss Program

By signing below, I confirm that:

- I have reviewed the weight loss program, its risks, and expectations.

- I understand that medications may affect blood pressure, blood sugar, and insulin sensitivity and require regular monitoring.

- Weight loss results vary, and no specific outcome is guaranteed.

- I agree to attend follow-ups and report any unusual symptoms immediately.

- I acknowledge that failure to comply with medical recommendations may result in discontinuation of treatment.

Charlotte Weight Loss & Wellness Clinic

Charlotte Weight Loss & Wellness Clinic

Patient Registration & Financial Responsibility

Pharmacy Information

Emergency Contact Information (Optional):

Weight & Medical History

Current Measurements (If unavailable, use last recorded vitals.)

Weight Medical History

Weight History (Estimate as closely as possible.)

Social History

Personal Medical History

Sleep Health

Cardiovascular Health

Medical History

Endocrine & Metabolic Health

Gastrointestinal Health

Respiratory Health

Musculoskeletal Health

Gynecologic & Obstetric Health

Medications (Include vitamins & supplements. Attach list if needed.)

Family & Weight Loss History

Food Intake & Dietary Habits

Dietary Restrictions

HIPAA & Privacy Acknowledgment

Photo Release Consent for Social Media & Marketing

Informed Consent: Semaglutide & Tirzepatide for Weight Loss

Possible Side Effects: (Initial to Acknowledge)

Exclusions from GLP-1 Weight Loss Program

Warnings & Precautions

Anesthesia & Surgery Precautions

Patient Acknowledgment

Charlotte Weight Loss and Wellness Clinic Disclaimer

Consent to Participate in the Charlotte Weight Loss Program

Charlotte Weight Loss & Wellness Clinic

Charlotte Weight Loss & Wellness Clinic

Patient Registration & Financial Responsibility

Pharmacy Information

Emergency Contact Information (Optional):

Weight & Medical History

Current Measurements (If unavailable, use last recorded vitals.)

Weight Medical History

Weight History (Estimate as closely as possible.)

Social History

Personal Medical History

Sleep Health

Cardiovascular Health

Medical History

Endocrine & Metabolic Health

Gastrointestinal Health

Respiratory Health

Musculoskeletal Health

Gynecologic & Obstetric Health

Medications (Include vitamins & supplements. Attach list if needed.)

Family & Weight Loss History

Food Intake & Dietary Habits

Dietary Restrictions

HIPAA & Privacy Acknowledgment

Photo Release Consent for Social Media & Marketing

Informed Consent: Semaglutide & Tirzepatide for Weight Loss

Possible Side Effects: (Initial to Acknowledge)

Exclusions from GLP-1 Weight Loss Program

Warnings & Precautions

Anesthesia & Surgery Precautions

Patient Acknowledgment

Charlotte Weight Loss and Wellness Clinic Disclaimer

Consent to Participate in the Charlotte Weight Loss Program

Forms Sent!