New Patient Packet

Patient Information

Last Name

First Name

Date of Birth

Marital Status

Single Married Partnered Separated Divorced Widowed

Home Phone

Cell Phone

Social Sec. #

Mailing Address

Employer

Emergency Contact

Emergency Contact Phone

Release of Medical Information

Voicemail Preference

Leave message with detailed information

Leave callback number only

Written Communication

Email Address

Mailing Address

Normal Test Results

Home

Cell

Mail

Authorized Person

Abnormal Test Results

Home

Cell

Mail

Authorized Person

Insurance Information

Primary Insurance

Secondary Insurance

Policy #

Group #

Policy #

Group #

Claims Address

City, State, Zip

Policy Holder Name

Policy Holder DOB

Policy Holder SSN

Policy Holder DOB

Policy Holder SSN

Assignment of Insurance Benefits/ Consent for Treatment

I, the undersigned hereby authorizes the release of any information relating to all claims for benefits submitted on my behalf or dependent's. I further agree and acknowledge that my signature on this document authorizes my physician to submit all claims for benefits for services rendered without obtaining my signature on each and every claim and that these claims may be paid directly to her. Also, I hereby grant Dr. Brooks and her medical staff to perform such medical procedures as discussed with me as deemed necessary. If the above patient is a minor, I am granting permission for treatment and I am an authorized person to do so. I have also received a copy of the "Notice of Privacy Practice" upon request and if I have any questions, I may discuss them with the staff. I also understand the financial policy to be:

Payment is due at the time of service and a $5-statement fee will be added to unpaid accounts. Returned checks will incur a $25-service fee.
A $50 cancellation fee will apply to appointments cancelled less than 24 hours in advance.
Account past 45 days are patient's responsibility per state law. Unless prior arrangements have been made with our office.
Accounts past 90 days will be referred to collections. A $100 collection fee will be added to accounts referred to collections and once with the agency, the patient must deal directly with the collection agency to clear the account.
By signing below, you acknowledge you have read and understood the above information.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

Medical Intake Form

Visit Date

PATIENT INFORMATION

Patient Name

Date of Birth

Age

Reason for Visit

DRUG ALLERGIES

Add Allergy

CURRENT MEDICATIONS: Include the name, strength/dose, & frequency taken for all prescribed, over-the-counter drugs, vitamins, supplements, inhalers, etc:

MEDICAL PROBLEMS: List any medical conditions

SURGICAL HISTORY

Add Surgery

FAMILY HISTORY

Maternal relatives with breast, ovarian, uterine, or colon cancer?

Yes No

Family History? If "Yes" please indicate the family member. If member is deceased, please indicate with "(D)"

Yes No

SOCIAL HISTORY

Do you smoke cigarette?

Yes No Quit

If yes, how many per week?

If quit, provide year.

Do you drink alcohol?

Yes No Quit

If yes, how many per day?

If quit, provide year.

Do you smoke marijuana?

Yes No

Do you use any illicit/IV drugs?

Yes No

If yes, describe.

Exercise regularly?

Yes No

If yes, how many days/week?

Gynecology Intake Form

Visit Date

PATIENT INFORMATION

Patient Name

Date of Birth

Age

Marital Status

Single Married Partnered Separated Divorced Widowed

Occupation

Primary/Referring Physician

Primary Pharmacy

GYNECOLOGIC HISTORY (skip questions that do not apply)

MENSTRUAL AND PREGNANCY HISTORY

Total Pregnancies

Full Term

Premature

Miscarriages

Abortions

# of children

Menstruation started at age

Menopause started at age

Last menstrual period

Menstrual Periods

Regular

Irregular

Days between cycles

Days of bleeding

Flow (check one)

Light

Moderate

Heavy

SEXUAL ACTIVITY

Are you sexually active?

Yes No

Current Partners

Male Female Both

INFECTION HISTORY

If other, please specify.

CONTRACEPTION

Current method of birth control

Prescription Hysterectomy Tubal Vasectomy Other

Condom used?

Yes No

Prescription: Please specify

Other: Please specify

PREVENTIVE CARE

When was your last pap smear?

Result

Normal Abnormal

When was your last abnormal pap smear?

Not applicable

Have you needed any of the following for an abnormal pap?

Yes (Check all that apply)

No treatment required

Colposcopy

LEEP/ Laser/ Conization

Cryosurgery

Colposcopy: Year

LEEP/ Laser/ Conization: Year

Cryosurgery: Year

When was your last mammogram?

Result

Normal Abnormal

When was your last bone density scan?

Result

Normal Abnormal

When was your last colonoscopy?

Result

Normal Abnormal

Have you received the HPV vaccine?

Yes No

Have you received the COVID-19 vaccine?

Yes No

REVIEW OF SYSTEM

Please indicate any symptoms in the last 30 days AND/OR any symptoms currently

Extremely painful periods

Yes No

Frequent urination

Yes No

Breast lumps

Yes No

Abnormal vaginal discharge

Yes No

Pain/Burning w/ urination

Yes No

Breast pain

Yes No

Irregular vaginal discharge

Yes No

Incontinence (leaking)

Yes No

Nipple discharge

Yes No

Pelvic pain

Yes No

Blood in urine

Yes No

Painful intercourse

Yes No

OFFICE USE ONLY

HGT

WGT

Pulse

RESP

HCG

Request for Release of Protected Health Information (PHI)

Date of Birth

Social Security #

Street Address

City

State

Zip

Do hereby authorize the use and/or disclosure of my protected health information (PHI).

AUTHORIZED ENTITY

I request to have the information released

from or to the following entity

Name

Street Address

City

State

Zip

Phone

Fax

AUTHORIZED PROTECTED HEALTH INFORMATION

Complete record

Lab

Records of care

Confer with designated person(s) orally about information in my medical record

Other/Specify

Records of care from - to

Other

I understand that the release of medical records may involve making available to myself or to others information of a personal nature. Issues with regard to personal use of cigarettes, alcohol, and other drugs, as well as possible exposure to infectious disease may be part of the medical record.

HIV/AIDS

Initials

I consent to the release of any positive or negative test results for AIDS or HIV infection, antibodies to AIDS or infection, anitbodies to AIDS infection with any other causative agents of AIDS with the rest of my medical records.

Yes No

PURPOSE OF DISCLOSURE

Medical Care

Attorney

Insurance

Other

Employer

Other

I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal HIPAA privacy regulations. I hereby acknowledge that this consent is truly voluntary and valid until revoked, and that I may revoke request this consent at any time, in writing, except to the extent that action based on this consent has been taken. I further understand this authorization will expire in 180 days from the date of signature unless otherwise specified, whichever occurs first.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Legal Guardian

Date

Signature of Witness

Date

Patient Notice Regarding Laboratory Services

Dr. LaStrap will order laboratory tests as she feels necessary and appropriate for patient healthcare.

Insurance benefits constantly change and are very specific for each individual depending on the insurance plan.

Unfortunately, it is impossible for Dr. LaStrap to determine if your insurance plan will pay for the laboratory tests.

As such our office cannot accept responsibility for patient laboratory charges or any result out of pocket expenses to the patient.

Patient Name

Date of Birth

Patient Signature

Date

HIPAA Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

1. Uses and Disclosures of Protected Health Information

Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing healthcare services to you, to pay your healthcare bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment. We will use and disclose your protected health information to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party. For example, we would disclose your protected health information as necessary to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment. Your protected health information will be used, as needed, to obtain payment for your healthcare services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations. We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements; Legal Proceedings: Law Enforcement, Coroners, Funeral Directors and Organ Donors; Research: Criminal Activity, Military Activity and National Security, Workers' Compensation, Inmates. Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirement of Section 164.500.

Other Permitted and Required Uses and Disclosures Will be made only with your consent, authorization or opportunity to object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights

Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and receive a copy your protected health information. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restrictions to apply.

Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to receive this notice alternatively i.e. electronically.

You have the right to have your physician amend your protected health information. If we deny your request for an amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

This notice was published and becomes effective on/or before April 14, 2003.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:

Name

Signature

Date

In accordance with HIPAA guidelines, I give permission to release medical information to the following people:

Add Person

Signature

Date

Weight Control Expectations Questionnaire

The accompanying explanatory sheet discusses the importance of clearly delineating your expectations when participating in any kind of weight control program. This form has been designed to assist you in organizing your thoughts regarding exactly what it is you want for yourself. By first filling out this questionnaire as completely as possible, and then reviewing it with your physician, you will learn what can reasonably be expected to occur.

If other, please specify.

How much weight do you expect to lose?

What will happen if you don’t lose as much or that fast? How will you react?

If your weight loss slows down remarkably or even completely stops for a while, will you understand the difference between fat loss and water loss?

What size clothes do you expect to be able to wear when you reach your goal weight?

What do you expect from us as your medical counselors? Please be very specific:

Will it change your life in any way (for better or worse) when you reach your goal weight?

Do you expect to be doing anything you are not doing now? (Describe in detail)

Do you expect to STOP doing anything YOU ARE DOING NOW? (Describe in detail)

Will you be able to handle compliments about how you look when you are of normal size?

Will your "new" normal weight self" pose a threat to your relationship with "significant others?" (How specifically?)

How will family and friends respond to the "new you?"

Do you expect to get a better job?

Will you get more respect from other people? (Who specially)

Will you feel comfortable with these altered responses from others?

Will you be expected to perform better at work (or at home)?

Will you have to be more sociable than you are now?

Will you have to assume any new responsibilities (please describe)?

What will happen if some of your expectations don't come true? What might you do?

What do you expect to have to do to maintain weight the same?

Will you continue to watch your food intake?

Exercise?

Continue with professional medical monitoring?

For about how long?

Do you have any other expectations that those listed above?

Specifically, what are they? Please describe them in detail.

Patient Name

Date

Email Address

By signing this form, I understand that i may receive email communication from The Center for Medical Weight Loss from time to time related to my weight loss program. I also understand that I may elect to stop receiving such emails at any time by using "unsubscribe" link located at the bottom of the email communication.

HOW DO YOU EAT NOW

Breakfast

Snacks

Lunch

Drinks

Dinner

Sweets

For those who have not had permanent sterilization, a hysterectomy, spousal vasectomy or menopausal, a urine pregnancy test will be conducted every time you are evaluated on the scale, there will be a $5.00 charge per test.

This test is necessary for legal and safety purposes to protect an unknown pregnancy.

Name

Signature

Date

Patient Informed Consent for Appetite Suppressants

I. Procedure AND Alternatives

1. I, (patient or legal guardian) authorize D.S. Salter, M.D. and Why Weight, LLC to assist me in my weight reduction efforts. I understand my treatment my involve, but is not limited to, the use of appetite suppressants for more than 12 weeks and when indicated in higher doses than the recommended doses on the labels.

2. I have read and understand the following statements made by my doctor:

“Medications, including the appetite suppressants, have labeling worked out between the makers of the medication and the Food and Drug Administration. This labeling contains, among other things, suggestions for using the medication. The appetite suppressant labeling suggestions are generally based on shorter term studies (up to 12 weeks) using the dosages indicated in the labeling.

“As a bariatric physician, I have found the appetite suppressants helpful for periods far in excess of 12 weeks, and at times in larger doses than those suggested in the labeling. As a physician, I am not required to use the medication as the labeling suggests, but I do use the labeling as a source of information along with my own experience, the experience of my colleagues, recent longer term studies and recommendations of university based investigators. Based on these, I have chosen, when indicated, to use the appetite suppressants for longer periods of time and at times, in increased doses.

“Such usage has not been as systematically studied as that suggested in the labeling and it is possible, as with most other medications, that there could be serious side effects (as noted below).

“As a bariatric physician, I believe the probability of such side effects is outweighed by the benefit of the appetite suppressant use for longer periods of time and when indicated in increased doses. However, you must decide if you are willing to accept the risks of side effects, even if they might be serious, for the possible help the appetite suppressants use in this manner may give.”

3. I understand it is my responsibility to follow the instructions carefully and to report to the doctor treating me for my weight any significant medical problems that I think may be related to my weight control program as soon as reasonably possible. I will notify the physician if I am taking any anti-depressant medications.

4. I understand the purpose of this treatment is to assist me in my desire to decrease my body weight and to maintain this weight loss. I understand my continuing to receive the appetite suppressant will be dependent on my progress in weight reduction and weight maintenance.

5. I understand there are other ways and programs that can assist me in my desire to decrease my body weight and to maintain this weight loss. In particular, a balanced calorie counting program or an exchange eating program without the use of the appetite suppressant would likely prove successful if followed, even though I would probably be hungrier without the appetite suppressants.

II. Risks of Proposed Treatment:

I understand this authorization is given with the knowledge that the use of the appetite suppressants for more than 12 weeks and in higher doses than the dose indicated in the labeling involves some risks and hazards. The more common include: nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, psychological problems, medication allergies, high blood pressure, rapid heart beat and heart irregularities. Less common, but more serious, risks are primary pulmonary hypertension and valvular heart disease. These and other possible risks could, on occasion, be serious or fatal.

III. Risks Associated with Being Overweight or Obese:

I am aware that there are certain risks associated with remaining overweight or obese. Among them are tendencies to high blood pressure, to diabetes, to heart attack and heart disease, and to arthritis of the joints, hips, knees and feet. I understand these risks may be modest if I am not very much overweight but that these risks can go up significantly the more overweight I am.

IV. No Guarantees:

I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I also understand that I will have to continue watching my weight all of my life if I am to be successful.

V. Patient’s Consent:

I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained, or any questions I have concerning them have not been answered to my complete satisfaction. I have been urged to take all the time I need in reading and understanding this form and in talking with my doctor regarding risks associated with the proposed treatment and regarding other treatments not involving the appetite suppressants.

WARNING

IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THE PROPOSED TREATMENT, OR ANY QUESTIONS WHATSOEVER CONCERNING THE PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK YOUR DOCTOR NOW BEFORE SIGNING THIS CONSENT FORM.

Date

Time

Patient

VI. HEALTH CARE PROVIDERS DECLARATION:

I have explained the contents of this document to the patient and have answered all the patient’s related questions, and, to the best of my knowledge, I feel the patient has been adequately informed concerning the benefits and risks associated with the use of the appetite suppressants, the benefits and risks associated with alternative therapies and the risks of continuing in an overweight state. After being adequately informed, the patient has consented to therapy involving the appetite suppressants in the manner indicated above.

Physician’s Signature

Nutritional Product Payment Agreement

Payment is necessary for all nutritional products in full prior to services being rendered for the medical weight loss program. the payment is non-refundable and non-transferable. In the event that you are unable to complete the program, you will be able to complete the unused portion at a later date (up to 1 year from your last appointment). For is unexchangeable due to Department of Health Regulations.

I agree to the above:

Please provide us with the name and telephone number of your primary care physician, so that we could keep him/her informed of your progress.

Physician Name

Telephone #

Appointment Cancellation Policy

As a result of not having any available appointments in our schedule and in order to best serve our patients, the following policy is necessary:

There will be a $75 charge if you fail to cancel your scheduled appointment in 24 hrs. in advance or do not show up for your appointment. Your credit card will be charged $75 on the day of your visit if you fail to cancel your appointment prior to the scheduled time.

Payment in full is necessary prior to any treatment being rendered. The payment is non-refundable and non-transferable.

By signing below I agree that I was informed of this CMWL Policy.

Signature

Name

Date

Patient Name

Date

VITALS

B/P

Pulse

Medical Conditions

Allergies

Medications

LMP

Regular Heavy Light

Days

Clot Size

Cramps/ How often

Pads/Tampons

How Many

Sexually active

Y N

Total partners/Gender

Protection

Birth Control

Married/Single

Pregnancies: DOB/Type/Gender

Last Mammo/ Results

Colonoscopy/ Results

Bone Density/ Results

Last pap/ Results

Abnormal pap

Treatment

Surgeries

Add Surgery

Social

Occupation/ Where

Caffeine/ Type/ How much

Alcohol type/ How often

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