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New Patient Intake Form

Birthday
How did you hear about us?

Health & Wellness History

Are you currently under the care of a physician?
Yes
No
Did your doctor refer you to us?
Yes
No
Do you have any sensitivity to light or do you take any medications that make you sensitive to sunlight?
Yes
No
Do you currently drink alcohol?
Yes
No
Do you currently smoke or use tobacco?
Yes
No
Do you have any history with illegal drug use?
Yes
No
Please check all areas of treatment that interest you:
Do you have any of the following:

Patient Consent Form HIPPA (Privacy)

Patient Consent for Use and Disclosure of Protected Health Information


I consent for Transformation Weight Loss & Wellness to use and disclose Protected Health Information (PHI) about me to carry out Treatment, Payment, and healthcare Operations (TPO). The Notice of Privacy Practices provided by Transformation Weight Loss & Wellness describes such uses and disclosures more completely. I have the right to review the Notice of Privacy Practices prior to signing this consent. Transformation Weight Loss & Wellness reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to 2200 Georgetown Dr, Suite 102, Sewickley, PA 15143.


With this consent, Transformation Weight Loss & Wellness may:


Call the phone number listed in the Intake Form and leave a message on voicemail in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, patient statements, and any calls pertaining to clinical care, results, etc.


Mail to my home or other alternative location listed in the Intake Form, any items that assist the practice in carrying out TPO, such as appointment reminders and patient statements as long as they are marked "Personal and Confidential".


Email to the email address provided in the Intake Form, any items that assist the practice in carrying out TPO, such as appointment reminders and patient statements.


I have the right to request that Transformation Weight Loss & Wellness restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.


By signing this form, I am consenting to allow Transformation Weight Loss & Wellness to use and disclose my PHI to carry out TPO.

Red Light Consent

Consent for Services and Release of Liability

 

OVERVIEW OF TREATMENT:  You will be receiving a red light treatment utilizing an FDA Class II Medical Grade red light therapy Max Miracle 9600 – Doctor Professional Edition. The equipment is manufactured in an FDA-listed facility in St. Louis, Missouri.  The FDA lists the photobiomodulation table as a Class II medical device.  This 360-degree treatment utilizes 3,200 LEDs with over 9600 watts of power delivered to the body.  Red and near-infrared light have wavelengths of 630nm-940nm. The patented miracle foot/head system is also included in the treatment. Red and near-infrared light is effective for use on the skin's surface and penetrates up to two inches into the body.  The therapy is safe and natural, which enables it to be offered as an alternative treatment for various health conditions such as weight loss, muscle pain, joint stiffness, arthritis, detoxification, chronic pain relief, reduction of muscle tension, relaxation, improved circulation, skin purification, sinusitis, lowered side effects of diabetes, boosting the immune system, and lowering blood pressure.

 

During your initial visit, a body composition analysis will be completed including weight, percent of body fat, percent of muscle, etc. prior to the initial red light therapy session.  Your consultant will oversee and discuss the red light equipment and treatment in addition to answering any questions you have.  This is a painless procedure suitable for ages 18 and over, and you may feel warm light penetrating through your skin.  Following the red light treatment, patients will utilize a voluntary whole body vibration machine primarily for stimulating the lymphatic system for body drainage and filtration. Patients should immediately stop using the voluntary whole body machine if any dizziness, light headedness, or discomfort is felt.  Additional red light therapy treatments may be recommended for optimum results, and the Weight Loss program may also be explained to the patient expressing an interest in the 6-week program.

 

Regular activities may be resumed after the treatment, and patients are encouraged to drink a minimum of 80-120 ounces of water and, if participating in the Weight Loss Program, avoid alcohol over the next 24-hour period. 

 

Red Light Therapy treatment is a voluntary procedure, and potential risks and side effects may include but not be limited to skin redness, reaction, and/or heat sensitivity.  Red Light therapy is not recommended if you are pregnant, breastfeeding, being treated for active gall bladder and/or active cancer, have any photosensitivity to lights or are taking photosensitive drugs, have a history of seizures or vertigo, claustrophobia, feel any chest pain or discomfort.  Any new tattoos should be covered and not exposed.  Prior to any treatment, a Patient Intake Form must be completed and submitted. All patients may consult their physician(s) prior to any treatment or program.

 

PRIVACY POLICY:  We value your privacy, and the Health Insurance Portability and Accountability Act (HIPPA) requires us to provide you with this disclosure.  Transformation Weight Loss & Wellness will not disclose, sell, rent, or allow any privacy information to be shared with third parties without your consent.

 

OFFICE  POLICIES:  A 24-hour cancellation policy is required.  Cancellations within 24 hours of a reserved session will result in the loss of that session. Child care is not provided in this office, and children must be 12 years of age or older to accompany a patient.  Any patient photographs taken before and/or after beginning or completing a program are only for internal patient use.  No patient photographs will be used or reproduced in any form of marketing or related venue without the prior written consent of the patient.  First-time promotions may be used only once per patient.  All sales are final and non-refundable.  Special pricing and packages are subject to change at any time.

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