Patient Intake Form

PERSONAL INFORMATION

First name

Last name

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Birthday

Day

Month

Year

Height

Current Weight

Blood Pressure

Pharmacy Name

Pharmacy Phone

Pharmacy Fax Number

MEDICAL HISTORY

Primary Care Physician

Physician Name

Physician Phone

Current Medications

Alergies (if any)

Prior Surgeries

Do you have any chronic medical conditions? (e.g., diabetes, hypertension, heart disease)

Have you previously used any weight loss medications? If yes, please specify

LIFESTYLE INFORMATION

Do you follow a specific diet plan? if yes, please describe

Do you exercise regularly? If yes, please describe routine

Have you experienced any Sid effects from weight loss medications in the past? If yes, please describe

MEDICATION INFORMATION

Which compounded weight loss medication are you interested in? (Please check all that apply)

Semaglutide

Tirzepatide

Do you understand that these medications are prescribed as an adjunct to a reduced-calorie diet and increased physical activity?

Yes

TERMS & CONDITIONS

We are pleased to offer Tirzepatide and Semaglutide prescriptions as part of our personalized weight management services. To ensure a smooth and informed experience, please review the following terms and conditions. These guidelines are designed to provide clarity and protect both our patients and our team.

Prescription and Usage
- Medication Information: Tirzepatide and Semaglutide are prescribed to assist with weight management alongside a reduced-calorie diet and increased physical activity.
- Medical Advice: Your prescription is based on the information you provide during your consultation. It is important to follow your healthcare provider’s instructions regarding dosage and administration.

Patient Responsibilities
- Accuracy of Information: Ensure that all personal health information you provide is accurate and complete, including medical history, current medications, and any allergies.
- Adherence to Treatment: Follow the prescribed treatment plan, including diet and exercise recommendations, as outlined by your healthcare provider.
- Monitoring and Reporting: Regularly monitor your health status and promptly report any side effects or concerns to our team.

Medication Risks and Side Effects
- Possible Side Effects: Tirzepatide and Semaglutide may cause side effects, including nausea, diarrhea, and abdominal discomfort. It is essential to be aware of these potential reactions and report any adverse effects.
- Medical Supervision: Regular follow-up consultations are required to assess the effectiveness and safety of the medication.

Limitations of Liability
- Medical Advice and Treatment: While we strive to provide the best possible care, TRUsculpt Clinic, Dr. Fahad Khan, and our team are not liable for any adverse effects or outcomes resulting from the use of Tirzepatide or Semaglutide.
- No Guarantees: Results from the medication may vary based on individual factors, and no specific outcomes or guarantees are promised.
- Emergency Situations: For any medical emergencies or severe reactions, seek immediate medical attention or call 911. Our services are not a substitute for emergency care.

Refills and Continuity of Care
- Prescription Refills: Request refills through our designated process. Ensure timely reporting of your weight, blood pressure, and any changes in your health status.
- Treatment Continuity: It is your responsibility to maintain regular consultations and follow-up appointments to ensure ongoing care and adjustments to your treatment plan as needed.

Confidentiality and Data Protection
- Privacy: Your personal health information is confidential and will be handled in accordance with applicable privacy laws and regulations.

Acceptance of Terms By accepting our prescription services for Tirzepatide or Semaglutide, you acknowledge that you have read and understood these terms and conditions. You agree to comply with the treatment guidelines and accept the limitations of liability as outlined. You also agree that all payments made are non-refundable.

Contact Us If you have any questions or concerns regarding these terms, our team is here to assist you. Please reach out to us at info@trusculptclinic.com.

WAVIER & ACKNOWLEDGMENTS

By signing below, you acknowledge and agree to the following:

Medical Liability Release:
- I understand that SlimSculpt Wellness, Dr. Fahad Khan, and their team are not liable for any adverse effects or outcomes resulting from the use of Tirzepatide or Semaglutide. I release them from any medical liability or malpractice claims related to the prescription and use of these medications.
Non-Refundable Payments:
- I acknowledge that all payments made for prescriptions and services are non-refundable. I understand that this includes any fees associated with consultations and the medications themselves.
Insurance Information:
- I understand that SlimSculpt Wellness does not accept medical insurance at this time. All costs associated with prescriptions and services are to be paid out-of-pocket.
Medication Understanding:
- I have been informed about the potential risks and benefits of Tirzepatide and Semaglutide. I agree to follow the prescribed treatment plan and to report any side effects or concerns to the clinic.
Emergency Situations:
- In the event of a medical emergency or severe reaction, I will seek immediate medical attention or call 911. I understand that the services provided by SlimSculpt Wellness are not a substitute for emergency care.

By signing below, you confirm that you have read, understood, and agreed to the terms and conditions outlined above.

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Relationship to Patient (if applicable)