Consent

New Patient Consent Forms

This consent form below is only if you are completing a telehealth appointment with us.

Please call or text our office Monday through Friday, 8:30 AM to 3:00 PM to schedule an appointment..
Call: 903.708.2533
Text: 903.708.2533
Email: clinic@mpweightloss.com

New Patient Information Form

New Patient Consult & Follow Up appointments

We will give you a call with the next available appointment.

Your Name(Required)

First Last

Date of Birth(Required)

Sex at Birth:(Required)

Phone(Required)

Your Email Address(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Current Weight(Required)

Goal Weight(Required)

Height(Required)

Feet Inches

Have you had any history of the following?(Required)

Medullary thyroid cancer

Multiple endocrine neoplasia syndrome type 2 (MEN2).

Pancreatitis

Diabetes requiring insulin

None

Medications

Semaglutide is the active ingredient in Ozempic/Wegovy and Tirzepatide is the active ingredient in Mounjaro/Zepbound.

Which medication are you interested in?(Required)

GLP-1 injections

Phentermine (Adipex) *Requires in an office appointment

Contrave (Oral Medication) *Requires in an office appointment

Semaglutide is the active ingredient in Ozempic/Wegovy and Tirzepatide is the active ingredient in Mounjaro/Zepbound.

Please note that Phentermine (Adipex) and Contrave are only available as an in office appointment.

Medical History

Current Medications(Required)

Past Medical History(Required)

Past Surgical History(Required)

Drug Allergies(Required)

RELEASE OF INFORMATION

Your doctor and staff are not allowed to release information to anyone but the patient. If you would like our office to be able to discuss results or medical information with anyone besides yourself, please indicate below:

Choose one(Required)

Full Name

Relationship

Phone

Full Name

Relationship

Phone

AUTHORIZATION OF TREATMENT AND ASSIGNMENT OF BENEFITS

I hereby authorize Carter J. Moore, MD, and the MP Weight Loss Staff to consent for treatment as he deems necessary.

NOTICE OF PRIVACY PRACTICE PATIENT ACKNOWLEDGEMENT

I have received and/or reviewed this practice's Notice of Privacy Practices. The notices provide details about uses and disclosures of my protected health information that may be needed by this practice, my individual rights, how I may exercise these rights, and the practice's legal duties with respect to my information. I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all protected health information resident at, or controlled by, the practice. I understand that I may obtain this practice's current Notice of Privacy Practices upon request.

COLLECTION POLICY

I understand that all charges incurred become my responsibility. Though an insurance claim may be filed, as a convenience to me, I understand that any applicable co-pays, deductibles, or co-insurance amounts are due on the same day services are rendered. *We accept all major credit and debit cards. (Insurance will only be billed for any lab work.)

Consent of Treatment

Signature(Required)

By signing, you agree to the above information.