Patient Intake

1. Your information

Full legal name

Please enter your full legal name.

Date of birth

Please enter your date of birth.

Phone

Please enter your phone number.

Email

Please enter a valid email.

Emergency contact name

Please enter an emergency contact name.

Relationship

Please enter the relationship.

Emergency phone

Please enter an emergency phone.

2. Your goals

Starting weight (lbs)

Please enter starting weight.

Goal weight (lbs)

Please enter goal weight.

Height

ft in

Please enter height in feet and inches.

Why are you seeking weight-loss treatment? (briefly)

Please briefly share why you are seeking treatment.

3. Medical history (brief)

Allergies (medications, foods, other) — or write None

Please list allergies or write None.

Current medications / supplements — or write None

Please list medications/supplements or write None.

Medical conditions (e.g., diabetes, thyroid, heart, kidney, GI, mental health) — or write None

Please list medical conditions or write None.

Have you ever had pancreatitis (inflammation of the pancreas), now or in the past?

If Yes, Magi’s cannot provide GLP-1 therapy.

Yes No

Please answer the pancreatitis question.

Prior weight-loss attempts (diet, exercise, medications, surgery) — or write None

Please list prior attempts or write None.

Pregnancy / breastfeeding / trying to become pregnant

If any box other than “None of these apply to me” is checked, Magi’s cannot provide GLP-1 therapy.

None of these apply to me Currently pregnant or possibly pregnant Currently breastfeeding Trying to become pregnant

If you become pregnant, start breastfeeding, or decide to try to become pregnant during treatment, stop your medicine and tell us right away; treatment will not be restarted.

Please select one pregnancy / breastfeeding option.

Do you currently drink alcohol?

If Yes, Magi’s cannot provide GLP-1 therapy.

Yes No

Please answer the alcohol question.

4. Lifestyle (short)

Activity level

Sedentary Light Moderate Active

Please select an activity level.

Diet notes (typical meals, restrictions, preferences)

Please enter diet notes.

5. Patient acknowledgment

I confirm that the information I provided on this intake form is true and complete to the best of my knowledge. I understand that Magi’s Infusions LLC will use this information to help plan my GLP-1 weight-loss care, and that my supervising physician makes the clinical decisions for my treatment. I will tell Magi’s staff right away if anything on this form changes, including pregnancy or any pancreatitis symptoms.

I agree to the patient acknowledgment above.

Patient signature

Please provide a signature (draw or type).

Date

Please enter the date.

Printed name

Please enter your printed name.

Florida Weight-Loss Consumer Bill of Rights (Florida Statutes § 501.0575)

WEIGHT-LOSS CONSUMER BILL OF RIGHTS

(A) WARNING: RAPID WEIGHT LOSS MAY CAUSE SERIOUS HEALTH PROBLEMS. RAPID WEIGHT LOSS IS WEIGHT LOSS OF MORE THAN 1 1/2 POUNDS TO 2 POUNDS PER WEEK OR WEIGHT LOSS OF MORE THAN 1 PERCENT OF BODY WEIGHT PER WEEK AFTER THE SECOND WEEK OF PARTICIPATION IN A WEIGHT-LOSS PROGRAM.

(B) CONSULT YOUR PERSONAL PHYSICIAN BEFORE STARTING ANY WEIGHT-LOSS PROGRAM.

(C) ONLY PERMANENT LIFESTYLE CHANGES, SUCH AS MAKING HEALTHFUL FOOD CHOICES AND INCREASING PHYSICAL ACTIVITY, PROMOTE LONG-TERM WEIGHT LOSS.

(D) QUALIFICATIONS OF THIS PROVIDER ARE AVAILABLE UPON REQUEST.

(E) YOU HAVE A RIGHT TO:

1. ASK QUESTIONS ABOUT THE POTENTIAL HEALTH RISKS OF THIS PROGRAM AND ITS NUTRITIONAL CONTENT, PSYCHOLOGICAL SUPPORT, AND EDUCATIONAL COMPONENTS.

2. RECEIVE AN ITEMIZED STATEMENT OF THE ACTUAL OR ESTIMATED PRICE OF THE WEIGHT-LOSS PROGRAM, INCLUDING EXTRA PRODUCTS, SERVICES, SUPPLEMENTS, EXAMINATIONS, AND LABORATORY TESTS.

3. KNOW THE ACTUAL OR ESTIMATED DURATION OF THE PROGRAM.

4. KNOW THE NAME, ADDRESS, AND QUALIFICATIONS OF THE DIETITIAN OR NUTRITIONIST WHO HAS REVIEWED AND APPROVED THE WEIGHT-LOSS PROGRAM ACCORDING TO s. 468.505(1)(j), FLORIDA STATUTES.

Acknowledgment

I received a copy of the Florida Weight-Loss Consumer Bill of Rights before starting this program term.

I acknowledge the statement above.