Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.What is your current weight? * What I how Tell me about your goal weight *Tell me about your eating habits *Have you tried any weight loss medications before? *If Yes, how long ago did you stop taking it and which medications?Do you exercise? How often a week? *1. Are you currently pregnant or breastfeeding? *YesNo2. Do you have a history of pancreatitis? *YesNo3. Do you have a personal or family history of thyroid cancer (medullary)? *YesNo4. Are you taking any weight loss medications currently? *YesNo5. Do you have diabetes? (Type 1 ) *YesNoWeight Loss Program Consent AgreementI voluntarily consent to participate in the Qlinicare Medical Weight Loss Program. I understand that this program may include: * Nutritional guidance * Lifestyle and behavioral counseling * Physical activity recommendations * Prescription medications, including but not limited to GLP-1 receptor agonists and/or appetite suppressants MEDICATION RISKS I understand that medications used for weight loss may have potential side effects, including but not limited to: * Nausea, vomiting, or diarrhea * Constipation * Headache or dizziness * Changes in blood sugar levels * Possible cardiovascular or gastrointestinal effects I understand that rare but serious side effects may occur and that I should report any concerning symptoms immediately. NO GUARANTEED RESULTS I understand that: * Weight loss results vary from person to person * No specific outcome or amount of weight loss is guaranteed * Results depend on adherence to the program, lifestyle changes, and individual health factors LIFESTYLE RESPONSIBILITY I acknowledge that successful weight loss requires my active participation, including: * Following dietary recommendations * Engaging in regular physical activity * Attending follow-up visits as recommended * Taking medications as prescribed MEDICATION USE I agree to: * Use medications only as prescribed * Not share medications with others * Inform my provider of all medications and supplements I am taking MEDICAL DISCLOSURE I certify that I have provided complete and accurate medical history information, including: * Current medications * Medical conditions * Allergies I understand that failure to provide accurate information may affect my safety and treatment outcomes. RIGHT TO WITHDRAW I understand that I may withdraw from the program at any time, and that QliniCare reserves the right to discontinue treatment if medically necessary or if program guidelines are not followed. CONSENT I have read and understand the information above. I have had the opportunity to ask questions and agree to participate in the Qlinicare Weight Loss Program. Full Name ( Electronic Signature) *I have read and agree to the Weight Loss Program Consent *I consentDate *Acknowledgment *I understand that results are not guaranteed and require lifestyle changesSubmit
