Patient Forms

*Please complete ALL your Forms prior to appointment--All underlined forms related to your scheduled visit must be signed before your appointment

Forms for Weight Management

Weight Management Pre Screen Form

Bottumzup Medical weight loss clinic policies

Weight loss Consultation 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

Indemnification Clause

Practice Policy

HIPAA Privacy Policy

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OTHER FORMS

3-Month Follow up – Required Form & $50 Fee applies

***Now available! Self-Pay Lab Services

Adult Annual Physical Form

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

PreParticipation Physical Evaluation Form

Indemnification Clause

Practice Policy

HIPAA Privacy Policy

Forms for Telehealth

New Patient Consultation intake form

Telemedicine Informed Consent

Authorization to release healthcare information

Weight Management Pre Screen Form

Indemnification Clause

Disclosure Statement for Direct Primary Care

Practice Policy

HIPAA Privacy Policy

Anticoagulation Therapy Consent Form