New Patient Form

THIS FORM IS FOR PATIENTS WHO HAVE MADE AN ONLINE PURCHASE. If you have already filled this out, please ignore.

Please purchase a HOMEKIT before filling out this form. After filling out this medical history form a chart can be created for you. This chart will be given to the Physician. The Physician will contact you within 24-48 hours.

"*" indicates required fields

Step 1 of 11

First and Last Name*

Email*

Are you a New Patient or Existing Patient? (For HomeKits)*

Have you placed an order for a Homekit?*

Phone*

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Height*

Feet and Inches (Example: 5' 1")

Weight (lbs)*

Sex*

Male

Female

Allergies*

Past Medical History*

Please fill out as completely as possible.

Do you have any of the following conditions?*

Fibromyalgia

Chronic Fatigue Syndrome

Liver or Kidney problems

Heart Problems

High Blood Pressure

Thyroid Issues

Hormone Issues

Blood Clots

Pre/Peri/Post Menopause

Cancer

Stroke or Seizure

None

Check ALL that apply

Have you recently stopped or started smoking?*

Yes

I've never smoked

Are you taking any blood thinners?*

Yes

Are you pregnant or breast feeding?*

Yes

I'm a male

Past surgical history:*

Prescription medications you are currently taking:*

Non-Prescription medications, vitamins or supplements you are currently taking:*

Do you drink alcohol?*

Yes

I hereby authorize WildBerryMD and associates to assist me in my weight loss efforts. I understand that WildBerryMD is not my primary care provider. I agree to follow up with my primary care provider for my routine medical care, annual physical exam, labs and any acute and chronic medical conditions. I understand that I am responsible for reporting any changes in my health history and medications to WildBerryMD. I understand that the WildberryMD, Weight Loss program uses Natural HCG drops and Fatburner/B12 injections along with a calorie restricted diet and exercise to help me in achieving my weight loss goals.*

I Agree

Risk of Proposed Treatment

I understand that I will be having a video consult with WildBerryMD before the Natural HCG or Fatburner/B12 injections are shipped to me. I have had full opportunity to ask any questions, after reading this form, and those were answered. I understand that if I develop side effects from my natural HCG drops or Fatburner/B12 injections, I will discontinue use and notify WildBerryMD staff immediately and in the event the problem is severe leading to medical emergency, I will go to the nearest emergency room for evaluation and management.

Risks Associated with Being Overweight or Obese

I am aware that there are certain risks associated with remaining overweight or obese. Among them are tendencies to high blood pressure, to diabetes, to heart attack and heart disease, and to arthritis of the joints, hips, knees, and feet.I understand these risks may be modest if I am not very much overweight but that these risks can go up significantly the more overweight I am.

Allergies: Some products may contain soy, shellfish, nuts, milk and other ingredients. Please read all product labels for any Allergies and Information prior to purchase.*

I Agree

No Guarantee

Causes for being overweight or obese vary from person to person. Whether genetic or environmental, it should be noted that food intake, rates of metabolism and levels of exercise and physical exertion vary from person to person. This means weight loss results will also vary from person to person. By consenting to treatment, I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I understand that I will have to continue to monitor my weight all of my life if I am to be successful. By signing below, I certify that I have read and fully understand this consent form. I should not sign this form if I have any questions that have not been answered to my complete satisfaction.*

I Agree

I understand these injections are to be self injected in the frontal thigh area, as portrayed in the video below. I agree I will use the syringes and vitamins as directed.*

I Agree

I purchased a non-injectable product

I understand that my custom package is ordered for me. My vial or package I start at WildBerryMD will have an expiration date that is 30 days after opening. I understand , after the 30 day period, medications are considered expired and should be discarded by me.*

I Agree

I UNDERSTAND THIS IS A NON-REFUNDABLE PRODUCT AND CANNOT BE RETURNED.*

I Agree

CONSENT FORM: I acknowledge that I have received instructions and educational material from WildBerryMD for the administration of home injections. I acknowledge that the risks of injections has been discussed with me. I understand that these risks include, but are not limited to, local reactions, rashes, bruises, etc. - I understand that if I elect to do self-administered injections or if another designated individual gives me the injection, I should be attended for at least 30 minutes by a responsible adult to assist me in case of a severe reaction. - I agree to have on hand an epinephrine injector to use in case of a systemic reaction. I acknowledge that I have received instruction on its use and administration. I further understand that I must identify that the date of this medication is current. If not, I will call for a renewal of my medication. - I understand that it is my responsibility to maintain follow up appointments with my physician at WildBerryMD as needed. By signing this form, I assume full responsibility for receiving my injections and release WildBerryMD and its physicians from any liability or responsibility for any reactions, conditions or self-injection procedures in conjunction with the injection therapies.*

I AGREE

SIGNATURE. I HAVE READ THE ABOVE CONSENT FORM. (First and Last Name)*

How did you hear about us?*

Date SIGNED (mm/dd/yyyy):*

MM slash DD slash YYYY

Name

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