Fill it out the form below, or download it below. (Formulario en español a continuación)

We will review any medical issues, health history, and habits that need addressed so we can layout the perfect weight loss program and diet for your journey to the new skinny you!

Name

Date (ex. 07/01/2015)

Age

Date of Birth (ex. 07/01/1962)

Sex

Address

City, State, Zip

Cell # (ex. (803) 555-1212)

Home # (ex. (803) 555-1212)

Work # (ex. (803) 555-1212)

Email

Best way to reach you?

How did you hear about us?
Please select all that apply:
 Local magazine ad Word of mouth Social network Physician referral Search engine Business sign at location Other

Other, please explain:

Name of Primary Care Provider

City, State

Are you interested in a free consultation for Bioidentical Hormone Replacement Therapy?
 Yes No

Patient History & Physical

Are you allergic to any medications?

Name of medication and reaction

Prescription Drugs
(Please list all medication including any "as needed" medications, over the counter vitamins, and birth control)

Drug | Dosage | Frequency | Medical reason for taking prescription

Over the counter medication, vitamins, or supplements:

Drug | Dosage | Frequency

Please list all current medical problems

Medical History

Mark "C" for Current Condition, Mark "P" for Past Condition, or "Never".

Diabetes
Fatty Liver
Kidney Disease
Fatigue
Depression
Heart Disease
Anxiety
Eating Disorder
Polycystic Ovarian Syndrome
High Colesterol
Thyroid Disease
COPD/Emphysema
Liver Disease
Mental Illness
Snoring
Heart Attack
Hypertension
Bleeding Disorder
Alcohol Use
Osteoporosis
Fibromyalgia
ADD/ADHD
Cancer
Dumping syndrome related to surgery / gall bladder
Vitamin D Deficiency
Smoking

If cancer, where?

Estrogen Fed?

If smoking, how long?

If smoking, have you quit?

If alcohol use, how often?

Gynecologic History

Pregnancies?

How many?

Dates:

Last menstrual period (ex. 07/01/2015)

Are they regular?

Have you had Hormone Replacement Therapy?

Birth Control

Type:

Surgical History

Have you had any surgeries?

List all and date

Family History

Age | Health | Disease |Overweight | Cause of Death

Father:

Mother:

Brothers:

Sisters:

Medical Disclaimer

All content posted on the Skinny Me, LLC website or materials given as reading resources are protected under free speech. Skinny Me, LLC has full ownership of and takes full responsibility for all content therein. You, the patient, are responsible for contacting your primary physician before beginning any weight loss program. You are required to complete an H & P (history of health and physical conditions) prior to your initial consultation. You are required to inform Skinny Me, LLC if ever diagnosed with any abnormal health conditions. The amount of weight loss per individual will vary. Skinny Me, LLC makes no claims as to the amount of weight loss per individual. Skinny Me, LLC has no control over an individual’s misuse of the program. Therefore, Skinny Me, LLC will not guarantee a specific weight loss amount. Skinny Me, LLC requires a deposit for ALL new and returning patients. This deposit is not refundable if the patient cancels within twenty-four hours of his or her appointment. Refunds will not be issued once a program begins. Full payment is expected at the initial consultation. Skinny Me, LLC will provide payment options for a finance fee of $20.00. The finance fee is non- refundable in the case of a terminated program. You will be expected to complete and sign a Payment Authorization Agreement at the initial consultation if payment is not rendered in full. Any voluntary blockage of payment due to Skinny Me, LLC will be turned over for collection. Any and all court costs, fines, and fees will be the responsibility of the patient. Multi-vitamin supplements are mandatory while on the program, while other supplements may be required on an individual basis. You assume complete responsibility for adverse reactions that may occur if you fail to adhere to these guidelines. Skinny Me, LLC is not responsible for any events or conditions in any manner or severity that may occur through misuse or failure to adhere to guidelines. Female patients please be advised of the following possible side effects: 1) Slight increase in fertility (less than 1%), 2) flow may increase during menstrual cycle, 3) spotting may occur. All patients are responsible for discarding any remaining hCG twenty-one (21) days after the printed date on the prescription label due to decreased potency. It is the patient’s responsibility to notify the pharmacy twenty-four (24) hours in advance of expected pick-up day of prescription. Patient prescriptions expire 9 weeks from the program start date. Please be advised that the Skinny Me with hCG weight loss plan is a 9-week program. Each patient agrees to complete the program in its entirety. Furthermore, any patient who needs to stop the program for any reason must notify Skinny Me, LCC immediately. Please be advised that by signing this disclaimer you are giving Skinny Me, LLC permission to contact you and/or leave messages regarding patient information via the indicated method(s) of contact: Cell Phone, Work Phone, Home Phone, E-mail, or Text Message, physical mail at home address. If you prefer Skinny Me, LLC to omit one of the aforementioned contact methods, please advise the staff immediately.

Acknowledgment of Receipt of Privacy Practices

This notice has been issued and considered effective on the date signed. We will keep this signed form on file for a minimum of (6) years.

 

General Hormone Injections Informed Consent

Hormones are generated by your body's endocrine glands and work as messengers to trigger certain tissues or organs to respond in different ways. Hormones can provide particular benefits such as: aid in growth and development, support metabolic activity, stimulate sexual function, help with reproductive purposes, and to enhance your mood. The body is very sensitive to the number of hormones in the bloodstream and a hormone imbalance can occur if there is too little or too much of the chemical. Sometimes an injection of a particular hormone may be necessary to support normal bodily function.

Hormone Injections and sublingual tablets common side effects include but are not limited to:

  1. Risks: I understand there is risk of hair loss, mild diarrhea, upset stomach, nausea, a feeling of pain and a warm sensation at the site of the injection, a feeling, or a sense, of being swollen over the entire body, headache and joint pain.
  2. If any of these side effects become severe or troublesome I will contact my physician immediately.
  3. I understand that although rare Hormone injections and sublingual tablets can result in serious side effects. Although this is a relatively rare occurrence, anyone taking Hormone injections or sublingual tablets should be aware of the possibility. Uncommon side effects are much more serious than the common side effects of Hormone injections and sublingual tablets, and such side effects should be reported to a physician to be evaluated for seriousness. Uncommon and dangerous side effects include, but are not limited to:
    • Headache
    • Tiredness
    • Digestive system problems
    • Menopausal symptoms (for females)
    • Effects on your muscles and bones
    • Weight gain
    • Memory problems
    • Mood swings and depression
    • Water retention
    • Indigestion or nausea
    • Sleeplessness
    • Problems getting an erection (for males)
    • Hot flushes and sweating
  4. Before starting the Hormone injections or sublingual tablets, I will make sure to tell my Physician if I am pregnant, lactating or have any of the following conditions.
    • Cardiovascular Endocrinology
    • Growth Disorders
    • Hormone Abuse
    • Menopause
    • Osteoporosis
    • Pituitary Disorders
    • Polycystic Ovary Syndrome
    • Reproductive Endocrinology
    • Thyroid Conditions/Disorders
    • Dependent on intravenous nutrition (TPN) or liquid nutrition products for food
    • Diabetes, mellitus, or high blood sugar levels
    • An unusual or allergic reaction other medicines, foods, dyes, or preservatives
  5. I understand that certain herbal products, vitamins, minerals, nutritional supplements, prescription and non- prescription medications may result in side effects when they interact with the Hormone injections or sublingual tablets.
  6. Treatments: Will be determined by the provider.

 

I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I further agree in the event of nonpayment, to bear the cost of collection, and/or Court cost and reasonable legal fees, should this be required.

By signing the H & P, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks. I hereby give consent to perform this and all subsequent Hormone Injections or sublingual tablets with the above understood. I hereby release the doctor, the person injecting the Hormone or administering the sublingual tablets, and the facility from liability associated with this program.

I have read the Medical Disclaimer*

Digital Signature (type your name)

 By signing this form you are confirming that all of the above information is true to the best of your knowledge.

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Contact Skinny Me

Hours

Mon. – Fri.
9 am – 5 pm

Address

Skinny Me
850 Cherry Road
Rock Hill, SC 29732

Phone

803-980-8446

Address

Skinny Me
1459 Stuart Engals Blvd.
Mount Pleasant, SC 29464

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Phone

843-352-9642

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If our standard business hours are not convenient, we may be able to met with you after hours.


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