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

Laboratory Requirements prior to Initiating any Weight loss Medications

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

Pre Screen Form

Indemnification Clause

Practice Policy

HIPAA Privacy Policy

=======================================

OTHER FORMS

Adult Annual Physical Form

Prior Authorization Consent

Disclosure Statement for Direct Primary Care

Pre and post IV Infusion

=======================================

PEDIATRIC FORMS

Pediatric consent form

New Pediatric Patient Registration Form

PreParticipation Physical Evaluation Form

Indemnification Clause

Practice Policy

HIPAA Privacy Policy

Forms for Telehealth

Telemedicine Informed Consent

Authorization to release healthcare information

Pre Screen Form

Patient Medical History Form

Indemnification Clause

Disclosure Statement for Direct Primary Care

Practice Policy

HIPAA Privacy Policy

Anticoagulation Therapy Consent Form