Appointment Date: Appointment Time: Dear Orion Member, We want to thank you for your interest in the Orion Weight Loss Program. We are looking forward to helping you reach your weight loss goal. Enclosed you will find our new patient paperwork. In order to minimize your wait, please take a few moments to complete the enclosed forms and bring it with you to your appointment. This is so we can better assist you with your healthcare needs. On the first day of your evaluation you will need to bring your enthusiasm and a positive attitude, we provide the rest. Again, thank you for your interest and we look forward to working with you! GOOD LUCK! Sincerely, Dr. Kroll and the Orion Staff
Welcome to our practice! Please Note: The first visit will take approximately 45 minutes to 1 hour. Please allow 24 hours notice for any cancellations. Being more than 15 minutes late to an appointment will result in rescheduling. New patients must bring a U.S. government approved I.D. For your convenience we accept cash, check, and credit cards. Payment for the evaluation is due at the time of service. Payments for all subsequent weigh-ins are due at the first visit of the week. All other visits for that week are included. We do not accept any insurance but some insurance companies do cover weight loss treatments. There is paperwork available that you may submit for repayment, but it is up to you to find out whether your insurance participates in this service. We require an EKG and blood work at the evaluation. Please do not wear any lotions or powders for the fact that it could interfere with these medical services. You are not required to complete the blood work outside of the office. Everything that is completed in the office that pertains to the assistance of your weight loss is included in the price of services.
Patient Information Name: Social Security #: Age: Date of Birth: Address: City: State: _ Zip: Home Phone: ( ) Cell Phone: ( ) Please Circle: Male Female Occupation: Email: _ Emergency Contact Information: Emergency Contact Phone: ( )_ Please List Any Current Health Concerns/ Conditions/ Symptoms: Please List Any Surgeries You Have Had:
Medications Currently Taking: Please List Any Drug Allergies: Have You Been Seen By A Medical Doctor In The Last Six Months? Name Of Primary Care Physician: Female Patients Only Do You Have Regular Periods? Have You Had Any Pregnancies? Is There Any Way You Could Be Pregnant?
Weight History Current Weight: Goal Weight: _ Height: Do You Smoke? If Yes, How Much? Do You Drink? If Yes, How Much? What Do You Believe Is The Source Of Your Weight Gain? (ie. Family History, Eating Habits, Pregnancy) Do You Have Any Food Allergies, Dislikes, Or Cravings? Have You Attempted Any Other Diets? If So, How Many? Why Didn t They Work Out For You? What Is Your Level Of Activity? Please Circle One: 0 1 2 3 4 5 (0 = Very Low and 5 = Very High)
What Dietary Problems Apply To You? Please Check All That Apply. Skipping Meals Carbohydrate Cravings Large Portion Size Too Much Alcohol Frequent Snacking Eating Fatty Foods Eating Out Frequently Stress Eating Eating Late Binging On Food What Is Your Motivation For Wanting To Lose The Weight? Please Check All That Apply. Unhappy With Appearance Need More Energy More Mobility Attending A Wedding/ Reunion Better Performance Gain Confidence Reduce Medications Upcoming Event/Vacation Clothes Do Not Fit Anymore Improve Health To Drop A Size To Improve Livelihood Other ( Please Describe)
Authorization of Medical Treatment I hereby authorize Dr. Brian C. Kroll, D.O. and his associates at First Choice Family Medical Center to provide any medical treatment, which in their judgment is deemed proper and medically necessary. Patient s Printed Name Patient s Date of Birth Patient, Guardian or Legal Representative s Signature Today s Date
Consent To Release Protected Health Information For Treatment, Payment, and Healthcare Operations I hereby authorize Dr. Brian C. Kroll, D.O. and his associates at First Choice Family Medical Center to release my personal protected information for treatment of my health condition to any other physician or healthcare provider directly or indirectly involved in my care and treatment. Direct involvement example: a specialist or hospital to which Dr. Brian C. Kroll has referred me to. Indirect involvement example: a laboratory, physicians of radiology or pathology. I understand that Mental Health, Substance Abuse, and HIV/AIDS related treatment will require an additional release of information authorization each time the information is requested for treatment purposes, except in any emergency treatment situation, as this is Dr. Brian C. Kroll s office policy. I understand that First Choice Family Medical Center will make all attempts to protect my confidential protected health information at all times. When the practice discloses my information it will be to authorized personnel and at the minimal amount of necessary information to accomplish the purpose. Some possible purposes include the purpose of billing, payment, and collections. I understand that I can request at any time an accounting of disclosure (release of information) for treatment, payment, or healthcare operations. I hereby consent and authorize First Choice Family Medical Center to use my protected health information for healthcare operations, such as quality assurance, improvement, healthcare oversight, and as required by federal and state laws. I understand that I may revoke this consent in writing at any time. Patient s Printed Name Patient s Date of Birth Patient, Guardian or Legal Representative s Signature Today s Date
Acknowledgment of Receipt of Notice of Privacy Practices I acknowledge that I have received a copy of First Choice Family Medical Center s Notice of Privacy Practices. I may request an additional copy from the practice at any time. I understand that I may ask if any changes have been made in the Notice of Privacy Practices, either each time I visit the office or by phone, and if there have been changes made to this Notice of Privacy Practices, the practice will provide me with a copy upon my request. Patient, Guardian or Legal Representative s Printed Name Relationship to Patient Patient s Printed Name Patient s Date of Birth To Staff Member: Upon request, a copy of this signed acknowledgment shall be supplied to the patient, guardian or legal representative. Staff Witness/Title Today s Date and Time Once processed, this form MUST be placed in the patient s medical records. Be sure to photocopy any ID s supplied by the patient, guardian, or legal representative. In the event of the patient s refusal to sign this acknowledgment, explain here and notify the provider. Initial, Date, and Time: Staff Witness/Title Today s Date and Time
Patient s Rights and Responsibilities Statement Statement of Patient s Rights Patients have the right to be treated with dignity and respect. Patients have the right to fair treatment, regardless of their race, religion, gender, ethnicity, age, disability, or source of payment. Patients have the right to have their treatment and other member information kept private. Only by law may records be released without patient permission. Patients have the right to easily access care in a timely fashion. Patients have the right to know all about their medical choices. This is regardless of cost or coverage by the patient s benefit plan. Patients have the right to share in the development of their plan of care. Patients have the right to information in a language they can understand. Patients have the right to have a clear explanation of their condition. Patients have the right to a clear explanation of their treatment options. Patients have the right to get information about their insurance carrier s services and role in the treatment process. Patients have the right to provide input on their insurance carrier s policies and services. Patients have the right to know the clinical guidelines used in providing and managing their care. Patients have the right to information about provider work history and training. Patients have the right to know about advocacy and community group and prevention services. Patients have a right to freely file a complaint, grievance, or appeal and to learn how to do so. Patients have the right to know about laws that relate to their rights and responsibilities. Patients have the right to know of their rights and responsibilities in the treatment process. Patient, Guardian or Legal Representative Signature Today s Date and Time
Patient s Rights and Responsibilities Statement Statement of Patient s Responsibilities Patients have the responsibility to treat those giving them care with dignity and respect. Patients have the responsibility to give providers information they need. This is so providers can deliver the best possible care. Patients have the responsibility to ask their providers questions about their care. This is so they can understand their role in that care. Patients have the responsibility to follow treatment plans for their care. The plan of care is to be agreed upon by the patient and provider. Patients have the responsibility to follow their agreed upon medication plan. Patients have the responsibility to tell their provider about medication changes, including medications given to them by others. Patients have the responsibility to keep their appointments. Patients should call their provider as soon as possible if they need to cancel visits. Patients have the responsibility to let their provider know when the treatment plan no longer works for them. Patients have the responsibility to let their provider know about problems with paying fees. Patients have the responsibility to not take actions that could harm others. Patients have the responsibility to report abuse. Patients have the responsibility to report fraud. Patients have the responsibility to openly report concerns about quality of care. Patient, Guardian or Legal Representative Signature _ Today s Date and Time
Weight Loss Bill of Rights WARNING: Rapid weight loss may cause serious health problems. Rapid weight loss is weight loss of more than 1 ½ pounds to 2 pounds per week or weight loss of more than 1% of body weight per week after the second week of participation in a weight loss program. Consult your personal physician before starting any weight loss program. Only permanent lifestyle changes, such as making healthful food choices and increasing physical activity, promote long term weight loss. Qualifications of this provider are available upon request. You Have a Right To Ask questions about the potential health risks of this program and its nutritional content, physiological support, and educational components. Receive an itemized statement of the actual or estimated price of the weight loss program, including extra products, services, supplements, examinations, and laboratory tests. Know the actual or estimated duration of the program. Know the name, address, and qualifications of the dietitian or nutritionist who has reviewed and approved weight loss program according to s.468.505(1)(j), Florida Statutes. Patient, Guardian or Legal Representative s Signature Today s Date
Controlled Substance Agreement Controlled substance medications are very useful but have a high potential for misuse and are, therefore, closely controlled by local, state and federal governments. Because my physician is prescribing controlled substance medications, I agree to the following conditions: 1. I am responsible for the controlled substance medication supplied to me. Refills will not be made if they RUN OUT EARLY, LOSE A PRESCRIPTION, or if MEDICATION HAS BEEN STOLEN. I am responsible for taking the medication in the dose prescribed and for keeping track of the amount remaining. I understand that I MUST be seen in the office every week in order to continue receiving prescription refills. Initials 2. I understand that the main treatment goal is to promote weight loss and improve my health. In consideration of this goal, and the fact that I am being given a potent medication to help me reach this goal, I agree to help myself by following better health habits such as exercising, weight control and the avoidance of the use of tobacco and alcohol. I must also comply with the treatment plan as prescribed by my physician. Initials 3. Female patient: I am aware that it is my responsibility to immediately inform the treating physician if I plan to or become pregnant. Pain management treatment including medications and injection therapy could result in harmful effects to the developing fetus. Initials 4. I understand that ID and signature are required for me or another individual to pick up prescriptions. Initials 5. I understand that if I violate any of the above conditions, my prescription for controlled substance medications may be terminated immediately. If the violation involves obtaining controlled substance medications from another individual, or the use of non-prescribed illicit (illegal) drugs, I may also be reported to all of my physicians, medical facilities, and appropriate authorities. Any repeated violation listed above could lead to being discharged from the Orion Rapid Weight Loss Program. Initials
Acknowledgment of Agreement I,, declare that I have received, read, understand, and agree with the Controlled Substance Agreement. The same will be explained to me by the physician as well. In addition, I fully understand the consequences of violating this agreement. Patient, Guardian or Legal Representative s Signature Today s Date Staff Witness/Title Today s Date and Time *This form is a necessary response due to changing regulations and enforcements. There is no assumption that you will purposely misuse your medications.
Waiver of Liability I have elected to seek medical treatment at the Orion Rapid Weight Loss Program, at the office of Dr. Brian C. Kroll, D.O. and understand that I am personally responsible for the payment of all services rendered. Any money owed will be paid in full on or before your next visit. Patient, Guardian or Legal Representative s Signature Today s Date
How Did You Hear About Us? Please let us know how you heard about our weight loss program, whether it was through one of our sources of advertisement or by word of mouth. Orion Rapid Weight Loss Program provides a rewards plan for those that refer patients to our office. For every patient that is referred to us and begins the program, we provide one free week. Please Circle: Commercial Billboard Newspaper/Newsletter Internet Friend Name:
Authorization to Utilize/Release Weight Loss Photographs I,, authorize Orion Rapid Weight Loss and Dr. Brian Kroll to use photographs I have provided for promotional, advertising, and marketing purposes as they see fit and appropriate. These marketing uses may include, but are not limited to: in-office bulletin board(s), website, flyers, television, commercials, etc. I release all copyrights to Orion Rapid Weight Loss for the aforementioned purposes. I understand that my photographs will not be sold or used for means other than marketing and advertising for Orion Rapid Weight loss exclusively. Patient, Guardian or Legal Representative s Signature Today s Date