New Patient Registration

Please take time to carefully fill out the form below. Once completed, read the consent for treatment in detail. Please submit the forms when reviewed and completed. Reach out with any questions or concerns.

New Patient Registration Form

First Name

Last Name

Birthday

Phone Number

Select an Address

Primary Care Physician

Height

Current Weight

Preferred Pharmacy

Please List ALL current Medications

Please List Any Medication Allergies

Please list any major surgeries (including any weight loss procedures):

Do you have any medical concerns that we should be aware of? If so, please explain:

Any personal or family history of thyroid cancer or MEN2?

Are you currently taking medications for weight loss (ozempic, semaglutide, mounjaro, etc.)

Emergency Contact

Emergency Contact Relationship

Phone Number

I certify that the above information is true and accurate. I authorize the release of any medical or other information necessary to continue medical treatment. I acknowledge that I am responsible for payment at time of service.

Thanks for submitting!

Southern Health Consent Form

I, ___________________________________, authorize my Southern Health LLC physician(s), or advanced practice clinician (s) and/or whomever may be designated as the medical assistant(s), to help me in my weight reduction efforts. I understand I will need to change my diet, exercise frequency and behaviors to aid in my long-term weight reduction efforts. I understand that the management of my weight will require a lifelong effort, no matter what method of weight reduction I choose. I understand that no drug can provide a quick fix for the problem of weight reduction and management. Other treatment options may include a very low caloric diet, or a protein supplemented diet. It has been explained to me to my complete satisfaction that these medications have been used safely and successfully in private medical practices as well as in academic centers for periods exceeding those recommended in the medication product literature.

I understand that any medical treatment may involve risks as well as the proposed benefits. I also understand that there are certain health risks associated with remaining overweight or obese. Risks associated with remaining overweight are tendencies to have high and increasing higher blood pressure, diabetes, heart attack and heart disease, arthritis of the joints including hips, knees, feet and back, sleep apnea, and sudden death. I understand that these risks may be modest if I am not significantly overweight, but will increase with additional weight gain.

I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances made to me that the program will be successful. I also understand that obesity may be a chronic, life-long condition that may require drastic changes in eating habits and permanent changes in behavior to be treated successfully.

Risks of semaglutide treatment include but not limited to: nausea, dysgeusia (altered sense of taste), dry mouth, insomnia, asthenia; burping; constipation; diarrhoea; dizziness; dry mouth; gallbladder disorders; gastrointestinal discomfort; gastrointestinal disorders; insomnia; nausea; vomiting, hypoglycemia, dyspepsia, gastritis, gastro-oesophageal reflux disease, flatulence, eructation, upper abdomen pain, abdomen distension, cholelithiasis, injection site reactions,

fatigue, increased lipase and increased amylase.

I am aware that other unforeseeable complications could occur. I do not expect the clinic to anticipate and or explain all risk and possible complications. I rely on them to exercise judgment during the course of treatment. I have been given all the time that I need to carefully read and understand this form.

Signed,

Patient Full Name: _______________________________ Date: __________________