Home » Weight Management New Patient Form

RadiateHealthy.com

Samantha Tronolone MSN, APRN, FNP-C
Info@radiatehealthy.com
407-349-3552

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Please submit the form below for a medical weight management consultation.
Once submitted we will contact you within 24 business hours to schedule a Telehealth consultation.

Eligibility for GLP-1 medical treatment includes BMI greater than 30 or BMI greater than 28 with at least one weight associated medical condition such as: Hypertension, Diabetes, High Cholesterol, Obstructive Sleep Apnea.

First Name*

Last Name*

Date of Birth*

Mailing Address*

Street Address City State / Province / Region ZIP / Postal Code

Phone*

Email Address*

Preferred Pharmacy Name

Address

Phone

We love referrals! Who referred you to us?

Allergies - Please list allergies and your reaction.*

Emergency contact information (Name & telephone number).

Gender at birth*

Male

Female

Date of last menstrual period

Have you gone through menopause?

Yes

“Are you pregnant, breast feeding, or plan to become pregnant?”

Yes

Are you on birth control? If yes, what type?

What is your ideal body weight?

What is your current weight?

What is your height?

Are you interested in compounded tirzepatide or semaglutide?

Semaglutide

Tirzepatide

Other

What is your motivation for weightloss?

Describe your Activity/Exercise.

Do you use tobacco products?

Do you drink alcohol? If yes, how often and how much?

Do you have or does anyone in your family have history of:

Medullary thyroid carcinoma (MTC)*

Yes

Multiple Endocrine Neoplasia syndrome type 2*

Yes

Have you ever had surgery? List surgery and date.

List all medications you are currently taking, including over-the-counter drugs, vitamins, and herbal supplements.

Medication

Dose

Used for

Please check the box to indicate yes. Leave blank for no.

Do you now or have you ever had any of the following medical conditions?

Thyroid Cancer or Thyroid disease

Yes

Date Diagnosed / Describe

Kidney Disease

Yes

Date Diagnosed / Describe

Pancreatitis

Yes

Date Diagnosed / Describe

Diabetes and/or Diabetic Retinopathy

Yes

Date Diagnosed / Describe

Depression

Yes

Date Diagnosed / Describe

Asthma

Yes

Date Diagnosed / Describe

Bleeding disorders or Stroke

Yes

Date Diagnosed / Describe

High Blood Pressure

Yes

Date Diagnosed / Describe

COPD

Yes

Date Diagnosed / Describe

Gastrointestinal problems

Yes

Date Diagnosed / Describe

Heart disease

Yes

Date Diagnosed / Describe

Menstrual problems

Yes

Date Diagnosed / Describe

Musculoskeletal conditions

Yes

Date Diagnosed / Describe

Psychological/psychiatric

Yes

Date Diagnosed / Describe

Seizures

Yes

Date Diagnosed / Describe

Any other medical conditions not listed?

Yes

Date Diagnosed / Describe

We take your privacy seriously! List names of person we are able to share your medical information with.

Weight Management (tirzepatide/semaglutide) Prescription Drug Management Agreement

This document is intended to serve as a confirmation of informed consent for compounded tirzepatide/semaglutide, which is a prescription weight management medication. The medication you receive is a compounded version that is not FDA approved.

A. Patient Informed Consent

I voluntarily request that my provider at Radiate Healthy treat my medical condition.

I have informed my provider of any known allergies, my medical conditions, medications, social/family history.

I have the right to be informed of any alternative options, side effects, and the risks and benefits.

I understand the mechanism of action of the medication.

I understand how it is to be administered.

I understand the prescription will come from a compounding pharmacy, which is not FDA approved.
I have been told that the manufacturing facility itself is FDA monitored along with third party testing on the medication itself.
The pharmacy is 503B or 503A certified.

Prices may vary and change. My charge will include my time with my provider (telehealth consultations, phone consultations, text, and e-mails), supplies, and medication.

My provider may change the pharmacy based on several factors.

It has been explained to me that this medication could be harmful if taken inappropriately or without advice from the provider.

I understand this medication may cause adverse side effects (see below). I understand this list is not complete and it describes the most common side effects, and that death is also a possibility of taking this medication. I understand symptoms may be worse after there has been a change in my medication dose or when first starting the medication.

Common side effects include, but are not limited to:

Gastrointestinal: Nausea/vomiting abdominal pain, Diarrhea/constipation, dyspepsia, abdominal distension, eructation, flatulence, gastroenteritis GERD, gastritis, lipase increase, amylase increase

Neurological: Headache, dizziness

Cardiac: Heart rate increase, Hypotension

Endocrine: Fatigue, hypoglycemia (diabetic patients), alopecia

Ophthalmic: Retinal disorder (diabetic patients)

Skin/hair: redness or pain at injection site, hair loss

Serious Reactions include, but are not limited to:

Thyroid C-cell tumor (animal studies)
Medullary thyroid cancer
Hypersensitivity reaction
Anaphylaxis
Angioedema
Acute kidney injury
Chronic renal failure exacerbation
Pancreatitis
Cholelithiasis
Cholecystitis
Syncope
Gastroparesis
Ileus

B. I understand that I have the following responsibilities:

1. I agree to obtain prescriptions for compounded tirzepatide/semaglutide only from Radiate Healthy.

If I am looking to transition to a non-compounding pharmacy or seek insurance coverage, I will tell my provider in advance.

2. Medical history: I will tell my provider my complete medical history, including: allergies, medications,
medical/surgical/social/family history.

My provider may ask to review, with my permission, my medical history (medications, recent lab results, pertinent imaging results).
I understand that if I become pregnant or start trying for pregnancy, I must stop this medication.
I will be honest to the best of my ability about my medical history.
I will tell my provider any updated health information (address changes, medication, allergies, personal medical issues/surgeries/social history, or family history changes).
My provider can discuss my treatment plan with any co-treating pharmacist and/or healthcare provider.
My provider will not discuss my health information with anyone else unless approve by me.
I agree to receive emails, text, other messages, regarding my healthcare.
I will always tell other providers about all medications I am taking.
My provider may ask for me to seek additional labs while on treatment to ensure its safety.
I attest I have none of the following medical conditions: Contraindications: Personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2), Pregnant or breast feeding, Past suicidal ideation, suicide attempt, uncontrolled psychiatric disorders, Allergies to GLP-1 medications, History of pancreatitis or severe alcohol abuse, Kidney impairment.

3. Directions for use: I will take my medications only as prescribed according to the directions, led by my provider.

If I feel my medications are not effective, or are causing undesirable side effects, I will contact my provider for instructions.
I will not adjust my medications without prior instruction to do so.
I understand this medication must be self-injected in the subcutaneous tissue once weekly. I will not inject at intervals any less than 7 days unless directed by my provider (example: travel).
I will not share needles and I will dispose of needles safely.
I understand this medical dosage is increased/decreased based on effectiveness and side effects.
If I’m having trouble with the administration of the medication, I will seek help from my provider.
My first will be taken in the presence of a friend/family member to ensure no allergic reactions.
I will properly dispose of unused medication. I will not use expired medications as per the manufacturer instructions.
My provider is not responsible for improper use, spills, broken vials or other loss of medication after the medication has been received.

4. Refills:

All refills will require an appointment or consultation.
I understand, I may need to schedule refill appointments ahead of time to avoid delays in refills.
I will not ask for early refills.
I understand that I may be asked to show the medication during my appointments to check the quantity left and my Provider may assess how I am injecting.
I understand dosage changes will change the duration of the course. Pricing is for 8-10 week course, but this will change if dosage is increased or decreased to achieve desired results.

5. Safety:

I understand it is important to keep my medication away from children (<18 years old)
I am the only one who will use my medication. I will not give or sell my medication to anyone else.
I attest that I am not currently pregnant, planning to become pregnant, and/or breastfeeding. I understand tirzepatide/semaglutide can be dangerous to a fetus and I would need to stop using the medication 2 months prior to becoming pregnant. I am using at least 2 forms of birth control to prevent pregnancy.
If I plan to have any surgical procedures I will stop this medication 2-3 weeks prior to the surgery.

6. If my provider deems it appropriate to start weaning my medication or transition to maintenance dosing, I will comply.

C. Discontinuation of medication: I understand that my provider may stop prescribing my medications if:

I am having unfavorable side effects or it’s not working to treat my medical condition.

I have been untruthful in my medical or family history.

I do not follow through with the recommended plan of care set by my provider.

I do not follow any parts of “Part B: responsibilities” in this agreement.

I hereby authorize the clinic’s staff on duty to act on my behalf to accept medication delivery from the clinic’s dispensing provider and deliver my medications and refills to me as prescribed by my provider. I understand that delivery of such medications can be picked up or mailed to my provided address on a weekly/monthly basis (or as often as ordered by the provider). This authorization will remain active for the course of my treatment at this clinic or until I revoke it in writing. If your state is not licensed by any of the compounding pharmacies, we are allowed to sign for the order and send it to you - the patient. Any orders delivered damaged or incomplete must be reported to RadiateHealthy within 24 hours of delivery and the pictures of damaged package/product must be sent to Info@RadiateHealthy.com. RadiateHealthy is not financially responsible or liable for lost or stolen items once delivered. Once items have been scanned as delivered to the customer's address, it is up to the customer to report any missing or stolen packages to RadiateHealthy within 24 hours of the delivery date. Any packages returned for an INCOMPLETE/INCORRECT address can be shipped again at the patient's expense.

No Guarantee of Services

We do not guarantee that any services or medications will be provided to you until you have undergone the full initial sign up process and provider’s examination. At the provider’s discretion only, you will be provided medications and/or services during your program at RadiateHealthy. RadiateHealthy requires you to have a as needed consultation with our provider and lab work. Lab work every 6 months is preferred but not required. Additional lab work can be requested by the provider at any time. No Refund Policy RadiateHealthy reserves the right to have NO RETURN and NO REFUND policy. I have read this form in its entirety. It has been explained to me. I have had the opportunity to ask questions and have all my questions answered. I fully understand the above information and have no further questions. By signing this form, I voluntarily give my consent for treatment and agree to the risks.

Patient Privacy Protection Form

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our Notice before signing this Consent. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on you prior Consent.
The patient understands that: Protected health information may be disclosed or used for treatment, payment or health care operations.
All other disclosures by the practice will require specific authorization by you unless required by law.
The Practice has a Notice of Privacy Practices and that the patient can review this Notice and receive a copy.
The patient has the right to restrict the uses of their information used for treatment, payment, or operations, but the Practice does not have to agree to those restrictions.

This is intended to serve as a confirmation of informed consent for medical treatment.

Patient Informed Consent

I voluntarily request that Radiate Healthy LLC treat my medical condition.

I have informed my provider of any known allergies, my medical conditions, medications, social/family history.

I understand that I have the following responsibilities:

Medical history: I will tell my provider my complete medical history, including: allergies, medications, medical/surgical/social/family history.
My provider may ask to review, with my permission, my medical history (medications, recent lab results, pertinent imaging results).
I will tell my provider any updated health information (medication, allergies, personal medical issues/surgeries/social history, or family history changes).
My provider can discuss my treatment plan with any co-treating pharmacist and/or healthcare provider.
I will always tell other providers about all medications I am taking.

HIPAA Compliance Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
Radiate Healthy LLC reserves the right to change the privacy policy as allowed by law.
Radiate Healthy LLC has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
Radiate Healthy LLC may condition receipt of treatment upon execution of this consent.

By signing this consent you agree that Radiate Healthy LLC can:
Leave a message on your answering machine at home or on your cell phone.
Contact you by phone, text message, or e-mail to confirm appointments.
Reply to text or e-mail to discuss treatment plans.

No Guarantee of Services

No Refund Policy

RadiateHealthy reserves the right to have NO RETURN and NO REFUND policy.

I have read this form in its entirety. It has been explained to me. I have had the opportunity to ask questions and have all my questions answered. I fully understand the above information and have no further questions. By signing this form, I voluntarily give my consent for medical treatment.

Patient signature

Date

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Phone

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Weight Management New patient Form

RadiateHealthy.com

Do you now or have you ever had any of the following medical conditions?

Weight Management (tirzepatide/semaglutide) Prescription Drug Management Agreement

A. Patient Informed Consent

Serious Reactions include, but are not limited to:

B. I understand that I have the following responsibilities:

1. I agree to obtain prescriptions for compounded tirzepatide/semaglutide only from Radiate Healthy.

2. Medical history: I will tell my provider my complete medical history, including: allergies, medications,
medical/surgical/social/family history.

3. Directions for use: I will take my medications only as prescribed according to the directions, led by my provider.

4. Refills:

5. Safety:

6. If my provider deems it appropriate to start weaning my medication or transition to maintenance dosing, I will comply.

C. Discontinuation of medication: I understand that my provider may stop prescribing my medications if:

No Guarantee of Services

Patient Privacy Protection Form

This is intended to serve as a confirmation of informed consent for medical treatment.

Patient Informed Consent

I understand that I have the following responsibilities:

HIPAA Compliance Patient Consent Form

No Guarantee of Services

No Refund Policy

Quick Links

Contact Us

Follow Us

Weight Management New patient Form

RadiateHealthy.com

Do you now or have you ever had any of the following medical conditions?

Weight Management (tirzepatide/semaglutide) Prescription Drug Management Agreement

A. Patient Informed Consent

Serious Reactions include, but are not limited to:

B. I understand that I have the following responsibilities:

1. I agree to obtain prescriptions for compounded tirzepatide/semaglutide only from Radiate Healthy.

2. Medical history: I will tell my provider my complete medical history, including: allergies, medications, medical/surgical/social/family history.

3. Directions for use: I will take my medications only as prescribed according to the directions, led by my provider.

4. Refills:

5. Safety:

6. If my provider deems it appropriate to start weaning my medication or transition to maintenance dosing, I will comply.

C. Discontinuation of medication: I understand that my provider may stop prescribing my medications if:

No Guarantee of Services

Patient Privacy Protection Form

This is intended to serve as a confirmation of informed consent for medical treatment.

Patient Informed Consent

I understand that I have the following responsibilities:

HIPAA Compliance Patient Consent Form

No Guarantee of Services

No Refund Policy

Quick Links

Contact Us

Follow Us

2. Medical history: I will tell my provider my complete medical history, including: allergies, medications,
medical/surgical/social/family history.