Elite Health Solutions Health History Intake & Consent

Please sign to document that this health history is accurate and that any current or past conditions have been identified truthfully.

Weight Management Prescription Drug Management Consent

This is intended to serve as confirmation of informed consent for compounded Semaglutide or Tirzepatide or any similar GLP-1 medications, which are prescription weight management medications. These medications are a GLP-1 (Glucagon-Like Peptide-1) and is a hormone that can help control blood sugar levels and appetite. Compounded GLP-1 medications may be prescribed for weight loss, in combination with a healthy diet and exercise. No guarantees are made to me regarding the effectiveness or outcome of this treatment. The use of compounded GLP-1 medications for weight loss is at the discretion of my medical provider based on my individual health needs.

A.    Patient Informed Consent

1.    I voluntarily request that Elite Health Solutions licensed practitioner treats my medical condition specifically related to obesity.

2.    I have informed my provider of any known allergies, my medical conditions, medications, social/family history.

3.    I have the right to be informed of any alternative options, side effects, and risks and benefits.

4.    I understand the mechanism of action of the medication.

5.    I understand how it is to be administered.

6.    I understand the prescription medication will come from a compounding pharmacy, and is not FDA-approved. I have been told that the manufacturing facility itself is FDA monitored, along with third-party testing on the medication itself.

7.    Prices may vary and change. My charge will include my time with a licensed practitioner (in person and via communication outside of the office), supplies, and medication.

8.    Elite Health Solutions may change the pharmacy based on several factors (availability, shipping time, cost).

9.    It has been explained to me that this medication could be harmful if taken inappropriately or without advice from the provider.

10.    I understand that this medication may cause adverse side effects (see below). I understand this list is not complete, and it describes the most common side effects and that death is also a possibility of taking this medication. I understand symptoms may be worse after there has been a change in my medication dose or when I am first starting the medication.

Common side effects include, but are not limited to:

•    Gastrointestinal: Nausea/vomiting, abdominal pain, diarrhea/constipation, dyspepsia, abdominal distension, eructation, flatulence, gastroenteritis, GERD, gastritis, lipase increase, amylase increase

•    Neurological: Headache, dizziness

•    Cardiac: Heart rate increase, Hypotension

•    Endocrine: Fatigue, hypoglycemia (diabetic patients), alopecia

•    Ophthalmic: Retinal disorder (diabetic patients)

•    Skin: redness or pain at injection site

Serious Reactions include, but are not limited to:

•    Thyroid C-cell tumor (animal studies)

•    Medullary thyroid cancer

•    Hypersensitivity reaction

•    Anaphylaxis

•    Angioedema

•    Acute kidney injury

•    Chronic renal failure exacerbation

•    Cholelithiasis

•    Cholecystitis

•    Syncope

B.    I understand that I have the following responsibilities:

1.    I agree to obtain prescriptions for compounded Semaglutide only from Elite Health Solutions.

a.    If I am looking to transition to a non-compounding pharmacy or seek insurance coverage, I will tell the provider in advance.

2.    Medical history: I will tell the provider my complete medical history, including: allergies, medications, medical/surgical/social/family history.

a.    The provider may ask to review, with your permission, your medical history (medications, recent lab results, pertinent imaging results).

b.    I understand that if I become pregnant or start trying for pregnancy, I must stop this medication.

c.    I will be honest to the best of my ability the history the provider needs to know.

d.    I will tell my provider any updated health information (medication, allergies, personal medical issues/surgeries/social history, or family history changes).

e. My provider can discuss my treatment plan with any co-treating pharmacist and/or healthcare provider

f. I will always tell other providers about all medications I am taking.

g. Elite Health Solutions may ask for me to seek additional labs while on treatment to ensure its safety.

3. Directions for use: I will take my medications only as prescribed according to the directions, led by my Elite Health Solutions provider.

a. If I feel my medications are not effective or are causing undesirable side effects, I will contact my provider for instructions.

b. I will not adjust my medications without prior instruction to do so.

c. I understand that the medication must be kept refrigerated.

d. I understand this medication must be self-injected in the subcutaneous tissue once weekly. I will not inject any less than 7 days unless directed by my provider (example, travel).

e. I will not share needles and dispose of needles safely.

f. If I’m having trouble with the administration of the medication, I will seek help from Elite Health Solutions.

g. The medication expires after 12 weeks. I will refer to the Beyond Usage Date (BUD).

4. Refills:

a. All refills will require communication with Elite Health Solutions.

b. I understand I may need to schedule refill appointments (if required) ahead of time to avoid delays in refills.

c. Refills will be ordered after payment of medication has been made.

5. Safety:

a. I understand it is important to keep my medication away from children (<18 years old)

b. I am the only one who will use my medication. I will not give or sell my medication to anyone else.

6. If an Elite Health Solutions provider deems it appropriate to start weaning my medication or transition to maintenance dosing, I will comply.

C. Discontinuation of medication: I understand that a provider may stop prescribing my medications if:

a. I am having unfavorable side effects or it’s not working to treat my medical condition

b. I have been untruthful in my medical or family history

c. I do not follow through with the recommended plan of care set by Elite Health Solutions.

d. I do not follow any parts of “Part B: responsibilities” in this agreement.

I have read this form in its entirety or it has been explained to me. I have had the opportunity to ask questions and have all my questions answered. I fully understand the above information and have no further questions. By signing this form, I voluntarily give my consent for treatment and agree to the risks.

HIPAA

INFORMATION and CONSENT

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003.

By signing this document you are granting consent for Elite Health Solutions, all affiliated providers, and all other supporting staff the authority to access any health records or medication history necessary to treat any medical conditions. You are consenting Elite Health Solutions to assessments and treatments necessary to treat you or clients under your guardianship. You are consenting to electronic communication (email, text, and telephone) reminders unless specified otherwise. 

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.

2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.

3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.

4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.

5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.

6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.

7. We agree to provide patients with access to their records in accordance with state and federal laws.

8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.

9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.