forms

*Please complete all your Forms prior to appointment

Forms for Weight Management

Laboratory Requirements prior to Initiating any Weight loss Medications

Bottumzup Medical weight loss clinic policies

Patient Medical History Form

Weight loss intake form

Lipotropic and B12 Informed Consent

Informed consent for Medical Weight loss management

BHW consent for photos and measurements

Authorization to release healthcare information

Pre Screen Form

Indemnification Clause

Practice Policy

HIPPA Privacy Policy

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OTHER FORMS

Prior Authorization Consent

Disclosure Statement for Direct Primary Care

Pre and post IV Infusion

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PEDIATRIC FORMS

Pediatric consent form

New Pediatric Patient Registration Form

Indemnification Clause

Practice Policy

HIPPA Privacy Policy

Forms for Telehealth

Telemedicine Informed Consent

Authorization to release healthcare information

Pre Screen Form

Indemnification Clause

Disclosure Statement for Direct Primary Care

Practice Policy

HIPPA Privacy Policy