New Patient Forms - MP Weight Loss Clinic

New Patient Consent Forms

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

Please call our office Monday – Friday 8:30 AM – 4:00 PM at 903.572.5882 to set an appointment.

New Patient Consent Form

Step 1 of 2

Name(Required)

First Last

Date of Birth(Required)

Sex(Required)

Email(Required)

Phone(Required)

Address(Required)

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

Name of Primary Care Physician

Known Drug Allergies(Required)

Emergency Contact

Name Relationship Phone Number

Which of the following medications are you interested in?(Required)

Phentermine

Semaglutide

Tirzepetide

I'm Not Sure

AUTHORIZATION OF TREATMENT AND ASSIGNMENT OF BENEFITS

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

COLLECTION POLICY

I understand that all charges incurred become my responsibility. I understand that any applicable amounts are due on the same day services are rendered. *We accept Visa, MasterCard, and Discover cards.

NOTICE OF PRIVACY PRACTICE PATIENT ACKNOWLEDGEMENT

I have received and/or reviewed this practice's Notice of Privacy Practices. The notices provides 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.

Informed Consent for Treatment:

The patient was given the option of a calorie restrictive diet, phentermine, tirzepatide, or semaglutide.

If phentermine was chosen, I understand that it will lose its effect over time and to maintain my new weight, I will need to restrict my calorie intake.

If semaglutide or tirzepatide is chosen, I agree to the following :

I do not have a history of MEN2 or Medullary Thyroid Cancer.
I understand that although rare, gallbladder disease, pancreatitis, or paralyzed intestines may occur. I should report to the office or other health care professionals if I experience any abdominal pain.
Weight loss is likely, but not guaranteed.
If nausea or vomiting occurs, I should report this to the office.
I should inform my PCP that I am using this medication.
I will come in approximately every three (3) months for a follow-up appointment.
If surgery is planned, I will stop these medications two weeks prior to surgery.
I understand that Tirzepatide and Semaglutide can decrease the absorption of oral birth control pills and may decrease their effectiveness. Other alternatives are available.
I will stop the medications if I decide to, or if I become pregnant.

RELEASE OF INFORMATION(Required)

Only to Myself

Other

Your doctor is 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:

Release of Information 1.

Name Relationship Phone Number

Release of Information 2.

Name Relationship Phone Number

Signature(Required)

Todays Date(Required)

Appointments

We will contact you within the next business day to schedule an appointment.

New Patient Consent Forms

New Patient Consent Form

AUTHORIZATION OF TREATMENT AND ASSIGNMENT OF BENEFITS

COLLECTION POLICY

NOTICE OF PRIVACY PRACTICE PATIENT ACKNOWLEDGEMENT

Informed Consent for Treatment:

Appointments

Semaglutide

Tirzepatide

Phentermine