New Patient Information

How did you hear about us? ____________________________________________________________ Patient Information Name Street Address City Primary Phone (H or W) Email Reason for Visit Explain complaints Weight Loss Goal Cell Phone Zip Date of Birth

Emergency

Emergency Contact Person Relationship List of Medications Allergies Problem List Past Medical History Select Any and All That Apply:

Phone

Medical Information

Prostate Cancer Deep Vein Thrombosis Pregnant

Do You Smoke?
For office Use Only Neck Waist Arm Hips

Estrogen Dependent Breast Cancer Polycythemia vera Breastfeeding How Many Every Day/Week?
Chest Thigh Ht BP Wt BMI P

Fat % ______ Fat Mass ________

Informed Consent for Treatment

I, ___________________________________, hereby authorize the physician employed or contracted by Your Ultimate Nutrition and Wellness to use the following to facilitate my diagnosis and treatment: Use of nutrition: (Therapeutic nutrition, nutritional supplements and intramuscular vitamin injections) Botanical medicine: (Teas, alcohol and glycerin extracts, solid extracts, capsules, tablets, creams, ointments and suppositories) Prescription medications: (HCG, hormonal or other prescription medications) Lifestyle counseling and hygiene: (Diet therapy, promotion of wellness including recommendations for exercise, sleep and stress.) Potential benefits: Restoration of health and the bodys maximum functional capacity. Potential risks: Allergic reactions to prescribed medications, herbs and supplements, side effects of natural medications, inconvenience of lifestyle changes, injury from injections, or procedures, tenderness/soreness or bruising from physical treatments. Notice to all pregnant women: All female patients must alert the doctor if they know or suspect that they are pregnant as some of the therapies used could present a risk to pregnancy. I understand that a record will be kept of the health services provided to me. This record will be kept confidential, and will not be released to others unless so directed by myself, my representative, or unless law requires. I understand that I may look at my medical record and can request a copy of my record by my paying the appropriate fee. I understand that my medical record will be kept no more than ten years after the date of my last treatment. I understand that the doctor will answer any questions that I might have. With this knowledge, I voluntarily consent to the above procedures. I realize that neither the doctor nor any personnel of Your Ultimate Nutrition and Wellness has made any absolute guarantees to me regarding cure or improvement of my condition. I understand that I am free to withdraw my consent and discontinue participation in these procedures at any time. I waive my right to future litigation regarding my present health condition by signing this agreement. I recognize the potential risks and benefits of these procedures as described above : Print Name: ___________________________________________________________________ Signature: ____________________________________________ Date: ___________________

Acknowledgement of Statement of Privacy Practices

The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility. Your Ultimate Nutrition and Wellness reserves the right to change the privacy practices that are describes in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me. Additional Disclosure Authority In addition to the allowable disclosure described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below. (Please circle) ANY MEMBER OF THE IMMEDIATE FAMILY: Y/N SPOUSE: Y/N OTHER (please Specify): Y/N ____________________________________________________ Name of Patient or Personal Representative__________________________________________ Signature of Patient or Personal Representative_______________________________________

0 Prescription Agreement Form

Because your health can vary over time, Your Ultimate Nutrition and Wellness only honors prescriptions for 12 months after the prescription is written. After 12 months another consultation with our doctor is required. HCG is given by prescription only. If I discontinue the Your Ultimate Nutrition and Wellness program for any reason, I understand that my initial prescription is valid for twelve months from the time the prescription is written. If there is no discontinuation of the program, the initial prescription is valid for one year. I hereby grant unto Your Ultimate Nutrition and Wellness permission to use my photograph and/or videotaped image for the purposes of training and promotion. I understand and agree that Your Ultimate Nutrition and Wellness may use these photos and/or videotaped images in subsequent years unless I revoke this authorization by notifying Your Ultimate Nutrition and Wellness in writing No Refund/Cancellation Policy I understand that I will pay for my sessions at the time service is rendered. I understand that Your Ultimate Nutrition and Wellness is a cash practice; therefore, my insurance will not necessarily cover any procedure or payment toward any of my sessions. Due to the medical nature of our business: NO Items can be returned due to possible contamination.
The Following Disclaimer is required by the FDA: HCG has not been demonstrated to be effective adjunctive therapy in the treatment of obesity. There is no substantial evidence that it increases weight loss beyond that resulting from caloric restriction, that it causes a more attractive or "normal" distribution of fat, or that it decreases the hunger and discomfort associated with calorie- restricted diets. The FDA has not approved HCG for weight loss.

INJECTION WAIVER and RESPONSIBLITY I have been trained on how to safely and effectively use syringes and needles and to dispose of them correctly by the medical staff at Your Ultimate Nutrition and Wellness. I now assume the responsibility of giving myself the injections prescribed by the doctor. This treatment is for me only; therefore, I will not give or administrate it to anyone else. By printing and signing my name below, I have agreed with this injection waiver and responsibility. Print Name: ___________________________________________________________________ Patient Signature: _______________________________________________________________ Date: ________________________________________________________________________

Referral Program
We appreciate you as our client. If you take the time to recommend us to a friend of family member and they book an appointment with us, we will thank you by taking $10.00 off your next product purchase. Please list the names and contact information of any of your family, colleagues, and friends that you feel would benefit from Your Ultimate Nutrition and Wellness. I may mention your name when I contact them. Thanks again for your business, and referring us to others.

Please list referral names, email, and phone numbers here: Referral's Name: ________________________________________________________________ Phone: ___________________________ Email Address: ________________________________

Referral's Name: ________________________________________________________________ Phone: ___________________________ Email Address: ________________________________

Referral's Name: ________________________________________________________________ Phone: ___________________________ Email Address: ________________________________