NEW PATIENT PACKET FEMALE

First Name

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Last Name

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Date of Birth:

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Address:

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City:

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State:

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Zip:

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Home Phone:

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Cell Phone:

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Age:

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Height:

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Weight:

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Occupation:

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Who referred you?

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Preferred Pharmacy:

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Pharmacy Phone:

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Emergency Contact Information

Name (First and Last):

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Relationship to patient:

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Home Phone:

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Cell Phone:

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Release Information

I hereby give permission to the person(s) listed below to receive information about the care of the above named patient.

Name(s):

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Date:

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Echelon Integrative reserves the right to charge for any scheduled visits that are:

Cancelled with less than 24 hour's notice
Are missed without calling to cancel (no show)

Cancellation Fee schedule: Existing patient $10.00

Health History

Past Medical History: Check all that apply

Cardiovascular Disease:

Chest pain

Heart Failure

Murmur

Vascular Disease

Blood Clots

Fainting

Lower Extremity Edema

Respiratory Disease:

Shortness of Breath

Asthma

Bronchitis

Pneumonia

Allergies

Hay Fever

Gastrointestinal Disease:

Lactose Intolerance

Gallbladder

GallStones

Diarrhea

Constipation

Genitourinary Disease:

Overactive Bladder

Frequent Urination

Painful Urination

Difficult Urination

Prostate Enlargement (BPH)

Any of the following medical conditions:

Diabetes

High Blood Pressure

Cancer

High Cholesterol

Depression

Sleep Apnea

Please list all prescribed medications and over-the-counter medication you are currently taking:

Name of Drug:

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Strength of Drug:

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Frequency Taken:

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Name of Drug:

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Strength of Drug:

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Frequency Taken:

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Name of Drug:

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Strength of Drug:

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Frequency Taken:

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Name of Drug:

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Strength of Drug:

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Frequency Taken:

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Name of Drug:

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Strength of Drug:

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Frequency Taken:

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Please list any allergies to medications:

Name of Drug:

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Reaction you had:

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Name of Drug:

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Reaction you had:

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Name of Drug:

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Reaction you had:

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Name of Drug:

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Reaction you had:

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Name of Drug:

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Reaction you had:

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Health Habits and Personal Safety

If you are a FEMALE, please choose "Yes" or "No" to the following:

Do you exercise?

Yes

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If yes, how often?

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If yes, what type of exercise?

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Do you consume alcohol?

Yes

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Do you use tobacco products?

Yes

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If you are a FEMALE, please circle "Yes" or "No" if you experience any of the following:

Hot flashes

Yes

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Vaginal dryness

Yes

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Hair loss

Yes

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Dry skin

Yes

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Decreasing sex drive

Yes

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Daytime sleepiness

Yes

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Moodiness

Yes

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Weight gain

Yes

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Increasing fatigue

Yes

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Please list any surgeries or hospitalizations you may have had previously:

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What was the date of your last breast exam and Pap test?

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What was the date of your last menstrual cycle?

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Informed Consent for Testosterone Replacement Therapy

Patient:

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DOB:

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Date:

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Testosterone replacement therapy includes use of products such as: injectable Depo-Testosterone, Testosterone Cypionate, Testosterone pellets, and topical products [patches and gel]. Testosterone replacement is approved for cases of primary hypogonadism as well as hypo-gonadotropic hypogonadism. Other uses may be considered "off label". The safety and efficacy of testosterone supplementation for off label use is not well established.

Contraindications:
You should not use testosterone if you have any of the following:

Known hypersensitivity to the drug
Breast Cancer
Prostate cancer
Serious Heart, Liver, Kidney disease
Women who are or may become pregnant

Potential Risks associated with testosterone use include, but are NOT limited to:

Application/Injection site reaction, Injury to muscle, Blood vessel and/or nerve damage at site,
Blood clots which could lead to: Heart Attack, Pulmonary embolism, and/or Stroke.,
Polycythemia, Exacerbation of Congestive Heart Failure or edema, Elevated Cholesterol.
Elevated Liver enzymes, Hepatitis, Hepatocellular Cancer, Elevated Creatinine levels.
Enlargement of Prostate, Worsening of Prostate Cancer, Elevated PSA, urinary retention.
Worsening of Sleep Apnea, Gynecomastia, Elevated Calcium levels.
Depression, Anxiety, Mood swings, Irritability, Suicidal Ideations.
Male pattern baldness, Acne, Virilization of women/children if exposed to topical.

Laboratory testing is REQUIRED prior to and during Testosterone replacement therapy. Regular follow up w provider for management during the course of treatment includes: consultation/discussion and routine labs.

Failure to comply with the required follow up appointments and monitoring, including lab work will result in the termination of therapy.

I have reviewed the risks and side effects that are associated with the use of Testosterone replacement products. I have had the opportunity to have questions answered. I consent to initiating/continuing treatment with Testosterone containing products. I agree to notify the office immediately if I suspect any adverse reactions or side effects from this treatment.

Provider Signature:

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Date:

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Notice of Privacy Practices

Federal and State HIPAA laws require that after April 14, 2003, all patients are informed of their medical provider's office privacy practices. We have instituted various safeguards and practices to protect your personal health information and we especially focus on keeping confidential any information that you may consider sensitive. In compliance with the HIPAA laws, we are providing you with a formal notice of our privacy practices. This notice is also posted in our reception area. In the normal process of our daily operations, we do need to disclose some information:

To remind you of upcoming appointments, we may call and leave a message, e-mail, or text stating the time and date of your appointment.
We may call, text, or e-mail to inform you of test and lab results.
For treatment, we may disclose your personal health information to physicians, nurses, and other care personnel who provide you with health care services or are involved in your care.

I request that all communication to me done by Chelsey Dobesh NP, and other staff at Echelon Integrative, be done with the following phone number, address, and e-mail address:

Phone number:

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May we leave a message?

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May we text appointment reminders?

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List those people we may leave a message with or speak with concerning your personal health information:

Name:

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Phone number:

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Relationship to patient:

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Name:

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Phone number:

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Relationship to patient:

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I have read this notice and was offered/received a copy from the office.

Credit Card Authorization Form

Name on card:

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Type of Card:

Visa

AmEx

Discover

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Card Number:

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Expiration Date:

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Security Code:

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Amount to be charged:

Monthly Hormone Treatment: $

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If an appointment is missed: $

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Add-Ons:

LipoLean - $40/mo 1x weekly $60/mo 2x weekly
Phentermine - $30 per bottle
MK677 - $75 per bottle
Sildenafil (Viagra) - $50 per bottle
Tadalafil (Cialis) - $50 per bottle

By signing this form, you authorize Echelon Integrative to charge your card for the amount listed above.

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Date:

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