Dr S Weightloss & Wellness, PLLC

Consent for Treatment/Disclosure & Financial Responsibility

Patient Name * Date of Birth *

I understand and agree that I am responsible for charges related to my treatment and obligated to pay my account with Dr S Weightloss & Wellness in accordance with its rates and terms. This includes copays, coinsurance, deductibles, and any non covered charges. A credit or debit card on file is required to schedule, maintain, and ensure appointments. Payment is due at the time of the service and for your convenience, we accept cash and all major credit cards. We don?t accept personal checks. Payment plans are available upon request.

Initial *

Missed appointments including coaching: If you are unable to keep an appointment with our practice, please notify us at least 48 hours in advance of your appointment. Failure to do so will result in a $150.00 charge for new patient appointments.. There is a $90 charge for medical follow up appointments, and a $50 charge for coaching. All missed appointment fees must be paid prior to your next visit. Three missed or last minute cancellation to appointments in a row will result in being discharged from the practice. Exceptions may apply!

Initial *

I consent to the treatment as prescribed by my provider and provided by Dr S Weightloss & Wellness, PLLC, its employees, or representatives. I have read and understand the consent for treatment, disclosure and payment agreement of this office and agree to abide this policy.

Patient signature * Date *

Consent for Use of Anti-Obesity Control Medications

Note: Signing this form doesn?t guarantee that Dr Nachida Hamidi-Sitouah (Dr S) will find you to be appropriate candidate for anti-obesity medications.

Some anti-obesity medications are considered ?controlled medications?, that by law, can only be prescribed from one facility at a time; therefore I agree that only Dr S Weightloss & Wellness PLLC will prescribe anti-obesity medications for me. I agree that it is my responsibility to inform Dr Nachida Hamidi-Sitouah and my other providers of all medications prescribed to me. I understand that the use of anti-obesity medications is contraindicated with certain medical histories, allergies, or other medication use. I agree that I will be honest in disclosing this information and will notify Dr S of any changes to my medical history or medication usage. I understand that failure to do so can be dangerous to my health.

I agree to take the medication only as prescribed and directed by Dr Nachida Hamidi-Sitouah, taking them in any other way could affect my health and be dangerous. I understand that the use of some of the anti-obesity medications beyond 12 weeks is considered ?off label? or not initially approved by the U.S. FDA and that Dr S will, at times choose, when indicated, to use these medication(s) for longer periods of time. I understand that I am to report to her any side effects or adverse reactions of my medications. I understand that the purpose of this treatment is to assist me in my desire to decrease my body weight for improvement of health and to maintain weight loss. I understand that the purpose of medications for weight loss is to be used as an adjunct to a program that includes nutrition and/or physical activity and/or behavior modification. I understand that much of the success of the program will depend on my efforts and that there are NO GUARANTEES in medical treatment of the disease of obesity. I also understand that I will have to continue monitoring my weight after active weight loss.

Patient signature * Date *

Authorization to Release/ Obtain Protected Health Information

Patient Name * Date of Birth *

I hereby authorize Nachida Hamidi-Sitouah/Dr S Weightloss & Wellness at 202 E Arlington blvd, suite D, Greenville, NC, 27858, Phone: (252) 227-0080, To RELEASE or OBTAIN my healthcare information to/from:

Referring Provider/Primary Care Provider/Other Name, Phone and Fax number: This authorization applies to: *

I do hereby consent and authorize you to release or obtain copies of my medical records.

I understand this authorization is valid for a period of one year after the date of the signature and may be revoked at any time prior to release of information. Dr S Weightloss & Wellness, its employees and physicians are released from legal responsibility or liability for the release of the above information to the extent indicated and authorized herein.

I have been offered a copy of the Notice of Privacy Practices and/or had it explained to me. I understand this notice and have had a chance to ask questions about any matters I don't understand.

Patient signature * Date *