Patient intake form

Name

Last Name

Password

Date of birth *

Cell Phone (Must be a cell phone to receive messages)

Address

City

State

Zip Code

I have read the consent for Semaglutide, Assisted Weight-Loss Program or any other prescribed medication

I understand that entering my name below constitutes an electronic signature

EMERGENCY CONTACT NAME

Full Name

Emergency contact relationship

Emergency contact phone

I have read and fully understand the above information related to participation in the
Semaglutide Assisted Diet Weight Management Program and the use of L-Carnitine,
B12 injectables and all other medications offered. I have had the opportunity to ask
questions and received answers regarding any issues. I understand the specifics and
limitations as described in this document. I accept all of the specific policy rules.

I understand that entering my name below constitutes an electronic signature

Are you under a doctor's care at the present time?

Yes

Surgeries & Other Hospitalizations

Allergies

Please list any medications you have known allergies to:

Prescribed Medications

Prescribed Medications, over-the-counter drugs, dietary supplements (include vitamins, inhalers, etc.)

Women Only - Are you pregnant, trying for pregnancy, or breast feeding?

Yes

I HEREBY DECLARE to the best of my knowledge, belief and intention, that the information I have submitted, on Elysian Wellness Center Personal Medical History Form and the Terms and Conditions forms are correctly recorded, complete and true. I agree that the Company, believing them to be true, shall rely and act upon them accordingly and make determinations based on my responses and answers. My accurate medical history information is required so that my doctor and staff have accurate current health information available. This information will be analyzed and reviewed by my diet physician and counselor who can then properly review, qualify, and treat me for all diet related services. I understand that this review is only applicable to the diet regimen with Semaglutide and that all other medical situations will be the responsibility of my primary care physicians. Elysian Wellness Center is a license Health Care Clinic Establishment in Florida that owns and operates the website this intake form is on.

I understand that entering my name below constitutes an electronic signature

Financial Policy
Please be advised that payment is due in full before starting the program. If paying with Credit or Debit, your charge will be from ELYSIAN WELLNESS CENTER , a licensed clinic in Miami, FL specializing in weight loss consulting and tutorials. There is no warrant or guarantee of results due largely to off-site administration and patient-controlled application of the diet program.
By submitting this intake form and moving forward with any order paid by credit or with debit card, you agree that any credit or debit card dispute should be resolved in favor of ELYSIAN WELL NESS CENTER . By signing below, you are acknowledging that you have read and agree to our Financial Policy. We have a no refund policy and office use or prescribed medications cannot be returned. Our fees include the consultation, order processing, costs of medications prescribed, and cost of supplies.

How many meals do you eat in an average day?

Do you drink alcohol?

Yes

How Often?

Do you use caffeine?

Yes

How Often?

Do you exercise?

Yes

How Often?

Current Weight in lbs

Goal Weight in lbs*

List any food allergies or foods that you avoid

FILE UPLOADS

FILE UPLOADS- IF YOU HAVE THEM NOW, PLEASE UPLOAD CURRENT LABWORK, HEALTH PHYSICAL EXAMINATION, AND DRIVERS LICENSE. IF YOU DONT HAVE THIS, SKIP THIS PART AND SUBMIT YOUR FORM.

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-Max. file size: 32 MB, Max. files: 5.

Please upload the following mandatory files for Semaglutide if you already have them, if you don't have them, skip this part and proceed to submit your form. We will need CURRENT LABWORK, a CURRENT HEALTH PHYSICAL exami/nation, and your DRIVERS LICENSE.

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