DAVID P. WILLETT, M.D. PO Box 1004, Suite 5-B East Owens Lane, Mauldin,SC 29662 Telephone: (864) 288-4765 BARIATRIC PATIENT INFORMATION SHEET FOR WEIGHT LOSS PATIENTS SSN______________________LAST NAME________________________FIRST NAME_______________________MIDDLE Name___________ ADDRESS_________________________________________________________________CITY___________________STATE______ZIP __________ PHONE: HOME_______________CELL___________________ DOB_____________EMAIL ADDRESS:________________________________________ MARITAL STATUS: M S D W EMPLOYMENT STATUS: _____________________________________________________________________ EMPLOYER NAME:__________________________________________________________________________ WORK PHONE:___________________ NAME OF YOUR FAMILY DOCTOR & GROUP________________________________________________________PHONE#:______________________ It is illegal in SC to see multiple doctors for weight loss medications during the same period of time. In addition, if your name is give as someone who is selling medications, whether true or not, you will be terminated from the program. We will notify DHEC and CRIMESTOPPERS of any illegal use of these controlled substances. ********************************************************************************************************* Have you ever seen another doctor for weight loss medication? Y or N Medication given?____________________________________ If YES, what is the Doctor's/Facility's name?__________________________________________________Last Date Seen_______/_______/_______ HOW DID YOU HEAR ABOUT OUR WEIGHT LOSS PROGRAM?________________________________________________________________________ Are you allergic to any medications? IF YES, WHAT?________________________________________________________________ List any current/chronic conditions that may prevent you from taking weight loss medications:____________________________________________ Do you take any medications DAILY? If YES, what?________________________________________________________________________________ Name & Location of Pharmacy commonly used:_____________________________________________________Phone#_______________________ Please circle if you smoke: Cigs, Cigars, Pipe, etc. How frequently?___________Do you drink alcohol? If yes, how much?______________________ Do you take illegal drugs? If yes, what and how much?____________________________________________________________________________ EMERGENCY CONTACT AND PHONE NUMBER:________________________________________________________________________ ********************************************************************************************************* Insurance Company_________________________________Name of Primary Insured_____________________________________ DOB of Insured:_________________ Dr Willett's office does NOT file insurance. ********************************************************************************************************** RELEASE OF INFORMATION I authorize Dr. David P. Willett to release any information acquired in the course of my medical examination and treatment. I authorize all information to be released to my insurance company, third party payers, case utilization, managed care review companies, Health Care Financing Administration. I further authorize information to be released to all other Dr. David P. Willett agencies, affilitated institutions or individuals who will be providing healthcare or social services to me. FINANCIAL AGREEMENT I accept responsiblity to ensure that all services are paid in full at date of service. Dr. Willett's office accepts cash, debit, or credit (not American Express). We do NOT accept CHECKS. Do you currently have a Living Will? Yes______ No______ Print Name:____________________________Patient's Signature_______________________________Date:_________________ Page 2 DAVID P. WILLETT, M.D. PO Box 1004, Suite 5-B East Owens Lane, Mauldin, SC 29662 Telephone: (864) 288-4765 SSN______________________LAST NAME________________________FIRST NAME_______________________MIDDLE Name___________ DR. WILLETT'S WEIGHT LOSS PROGRAM Welcome to my weight loss program. My goal is to help you regain healthy eating habits and improve your over all health. REQUIREMENTS FOR THE WEIGHT LOSS PROGRAM - You need to have a BMI of equal to or greater than 25 to receive weight loss medications.
- To effectively lose weight, you need to be consistent with reducing calories and participating in daily exercise.
- You must have a valid South Carolina Driver's license to receive weight loss medications.
- You must be compliant with my recommendations. Weight loss medications are only an aid to the overall weight reduction experience.
AUTOMATIC DISMISSAL OCCURS IF: - You are going to more than one physician for weight loss medications.
- Your name is given as someone who is reselling medications whether true or not.
- You do not keep your appointments or cancel your appointments repeatedly.
- You have any known drug related charges that are brought to our attention.
I understand weight loss medications may have side effects and I will not hold Dr. Willett responsible for adverse reactions as I am voluntarily requesting these medications. I have read and understand the requirements stated above for the weight loss program and am willing to participate. SIGNATURE_____________________________________________________DATE______________________ |