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What is your legal last name?*

Phone Number*

E-mail*

What is your date of birth?*

What is your date of birth?

What is your shipping address? (address, city, state)*

What is your zip code?*

What is your gender?

Male
Female
Prefer not to say

What is your height?*

What is your current weight? (in lbs)*

What is your weight loss goal?

1-15 lbs
16-50 lbs
51+ lbs
Not sure , I just want to lose weight

Are you taking any of the following medications?

Antidepressants called MAO inhibitors
Rybelsus or insulin for diabetes
Other medication not mentioned here
None of the above

Do you or anyone in your family suffer from tumors found in the thyroid, parathyroid, or adrenal gland , also known as Multiple Endocrine Neoplasia Type 2?

Yes
No

Have you ever been diagnosed with any type of cancer?

Yes
No

Have you ever had or currently suffer from any of the following conditions?

Pancreatitis or Gallblader Disease
Chronic Kidney Disease
Type 1 Diabetes or Currently Taking Insulin
A History of Heart Attacks or Strokes
Other Serious Medical Conditions Not Listed
None of the above

Are you currently pregnant, breastfeeding, or planning on becoming pregnant?

Yes
No
N/A

And finally, do you have any allergies or other medical conditions?*

Is there anything else you want the provider to know ?

How Did You Find Out About Us?*

Terms of Use Agreement Consent for the Purposes of Treatment, Payment, and Healthcare Operations I understand that, under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this form can and will be used to: Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in my treatment directly and indirectly. Obtain payment from third-party payers. Conduct normal healthcare processes such as quality assessments. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions. Furthermore, I agree to the best of my knowledge that all my answers to questions on the form are true and correct. Weight Loss Consent Form I authorize FeelGreat IV Hydration & Weight Management, and whomever they designate as their assistants, to help me in my weight reduction efforts. I understand that my program may consist of a balanced diet, a regular exercise program, instructions in behavior modification techniques, and may involve the use of medications to help with weight loss. It has been explained to me that these medications have been used safely and successfully in private medical practices as well as in academic centers. I understand that any medical treatment may involve risks as well as the proposed benefits. I also understand that there are certain health risks associated with remaining overweight or obese. 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 obesity may be a chronic, life-long condition that may require changes in eating habits and permanent changes in behavior to be treated successfully. 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 to me. My questions have been answered to my complete satisfaction. I have been urged and have been given all the time I need to read and understand this form. IV Hydration Consent Form I authorize FeelGreat IV Hydration & Weight Management, and whomever they designate as their assistants, to initiate hydration via IV infusion. I understand that my program may consist of a balanced diet, a regular exercise program, instructions in behavior modification techniques, and may involve the use of medications, vitamins, and supplements to help with hydration. It has been explained to me that these medications have been used safely and successfully in private medical practices as well as in academic centers. I understand that any medical treatment may involve risks as well as the proposed benefits. I also understand that there are certain health risks associated with remaining dehydrated and stressed. 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 stress and dehydration may be a chronic, life-long condition that may require changes in eating habits and permanent changes in behavior to be treated successfully. 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 to me. My questions have been answered to my complete satisfaction. I have been urged and have been given all the time I need to read and understand this form. By checking the box below, I agree to all the terms and conditions outlined in the above consents and forms.

I agree to the Terms of Use

Weight Loss Intake Form

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