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New Patient Form

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Personal Information




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Weight

Central (abdomen, hips, buttocks)General (all over, carries weight well)

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Sleep/Energy

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General

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Marital Status

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Present Health

How long did you participate in this/these other weight loss programs?

Kindly provide us information about whether you take some of following if yes then mention the quantity.

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Personal History

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Review of Symptom

Y= a condition you have now N= never had P= a condition you have had in past

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Females

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Males

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Indivudual Health Concern Questions

You can ask questions below.

Diet Doc Clinic Informed Consent for Treatment

I hereby authorize the

physician contracted by Perfect Health Technologies / DietDoc 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: (Antivirals, Dietdoc, antibiotics, antifungal, hormonal, or other prescription medications)
Physical medicine:(Massage therapy, muscle energy stretching, trigger point release, manipulation, hydrotherapy, or similar hands-on therapies)
Lifestyle counseling and hygiene: (Diet therapy, promotion of wellness including recommendations for exercise, sleep and stress.)

I recognize the potential risks and benefits of these procedures as described below:

Potential benefits: Restoration of health and the body’s maximum functional capacity without the use of drugs or surgery, relief of pain and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or its progression.
Potential risks: Allergic reactions to prescribed medications, herbs and supplements, side effects of natural medications, inconvenience of lifestyle changes, injury from injections, venipunctures or procedures, tenderness/soreness or bruising from physical treatments. Please note, the patient of DietDoc has a choice between obtaining the prescription from the dispensing prescriber associated with DietDoc or obtaining the prescription at a pharmacy of the patient's choice.
Side Effects: The DietDoc side effects to keep an eye out for include the onset of headaches, irritability, restlessness, slight water retention, tenderness of breast tissue, swelling of the injection site, and depression. There are some rare, severe side effects as well which include the development of ovarian hyper stimulation in females. The latter condition requires immediate medical treatment and is accompanied by the following symptoms: tremendous pain in the region of the pelvis, the swelling of feet, legs, and hands, abdominal pain, abdominal swelling, difficulty breathing, diarrhea, vomiting, nausea, a diminishing of urination, and weight gain. If a user of DietDoc products notes any side effects it is recommended that he or she cease using the products immediately and that he or she seek out the assistance of a physician.
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. There are no therapies at Diet Doc that are acceptable for pregnant woman.
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 Perfect Health Technologies / DietDoc 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.
Diet Doc has been providing weight loss care for almost a decade. We previously maintained two dozen physical locations and the success rate was in the low 60%. When telemedicine was offered, along with multiple, vital consultations with the weight loss doctors, nutritionists, nurses, care managers, your expected, success rate climbs to 98%. This only happens when all consults scheduled are kept and the personalized diet protocol is followed. Each consult has a purpose and is unique. You will receive an automated call reminder 2 days before each consult. Please keep these 4 consults to increase your chances for success. If you hit a plateau (weight loss slow down), call/email as there is always a reason why this could happen. You will be required to submit a food journal of what you consumed the past few days.
With this knowledge, I agree and consent to these consults and realize if I do not complete 4 consults within a 6 week period, my success rate could drop as much as 36%.

Acknowledgement of Receipt of Statement of Privacy Practices

I acknowledge that I have received a copy of the Statement of Privacy Practices for the office of Perfect Health Technologies/ DietDoc. 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.
Perfect Health Technologies / DietDoc 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

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Your privacy is very important for us, please let us know the best way to reach you and if we may leave a message during our weekly follow -up calls"

Diet Doc Guarantee

Diet Doc Weight Loss is a unique medically, supervised weight loss program which personalizes a diet for each person. In order to lose the weight desired, it's important that the overall program is followed specifically according to the Diet Doc workbook and weight loss doctor and nurse recommendation. If weight loss ceases or slows down by half, it's necessary to call or email Diet Doc as we are experts at reversing weight loss plateaus. All sales are final, product/medication cannot be returned.

If patient is seeking health care reimbursement, Diet Doc Weight Loss will provide documents and receipts for patient to submit to insurance company for reimbursement, but Diet Doc Weight Loss does not make claims or promises that the individuals health insurance will reimburse. This is 100% the patients responsibility.

Please present a photo ID so that we can retain a copy in your file in able to issue your prescription and comply with FDA regulations.

How did you hear or learn about our DietDoc Program?

Referred by: Please circle one: Friend Family Member Workmate Other
Referred by (name):

Statement of Privacy Practices- Diet Doc

Our office is dedicated to protect the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensure that your health information is never compromised is a principle concept of our practice. We may, from time to time, amend our privacy policies and practices but will always inform you of any changes that might affect your rights.

Protecting Your Personal Healthcare Information

We use and disclose the information we collect from you only as allowed by the Health Insurance Probability and Accountability Act and the state of Washington. This personal health information will never be otherwise given to anyone- even family members- without your written consent. You, of course, may give written authorization for us to disclose your information to anyone you choose, for any purpose.

Our offices and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality of your records is always protected. Our privacy policy and practices apply to all former, current, and future patients, so you can be confident that your protected health information will never be improperly disclosed or released.

Collecting Protected Health Information

We will only request personal information needed to provide our standard of quality care, implement payment activities, conduct normal practice operations, and comply with the law. This may include your name, address, telephone number(s), Social Security Number, employment data, medical history, health records, ECT. Perfect Health Technologies retains full ownership of all documentation collected, and reserves the right to duplicate it for treatment purposes. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law.

Disclosure of your Protected Health Information

As stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and governmental official under certain circumstances. We will not use your information for marketing purposes without your written consent.

We may use and/or disclose your health information to communicate reminders about your appointments including utilizing phone auto dialers to remind you of missed consults, follow-up to your diet, doctor renewals, etc., voicemail/answering machine messages, postcards, newsletters and special events.

Patient Rights

You have the right to request copies of your healthcare information; to request copies in various formats; and to request a list of instances in which we, or our business associates, have disclosed your protected information for used other than stated above. All such requests must be in writing. We may charge you for copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services.

We thank you for being a patient at our office. Please let us know if you have any questions concerning your privacy rights and the protection of your personal health information.

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Patient Acknowledges that he/she is financially responsible for the doctor's fee for a completed consultation in the event of requesting a refund at a later date

1. I understand that my health care provider wishes me to engage in a telemedicine consultation.

2. I understand how the telemedicine video/phone conferencing technology will be used to affect such a consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider. I understand that my health care provider wishes me to engage in a telemedicine consultation. Utilizing technology, I understand that DietDoc will reach out to me via auto dialers to check on my weight loss progress, notify me of missed consultations, or to notify me my prescription has expired, etc.

3. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

4. I have had the alternatives to a telemedicine consultation explained to me.

5. Customers / patients of Perfect Health Technologies (dba: Diet Doc Weight Loss) authorize Diet Doc Weight Loss to act as the customer/patients agent and (when necessary) receive medication prescribed by the doctor. This customer/patient prescription medication will be mailed to the patient the same-day or no later than 1 business day after receipt of said medication. The medication is normally placed in a box containing non-prescription Diet Doc support products. Medication is patient specific.

My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand. By signing this form, I certify: · That I have read or had this form read and/or had this form explained to me · That I fully understand its contents including the risks and benefits of the telemedicine consultation(s). · That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.