If using any Weight Management Medications, list above with medication name, dosage, date of last dose and length of time utilizing.  

Patient Financial Responsibility Agreement

I clearly understand and agree that all services rendered to me may be charged directly to me, and that I am personally responsible for full payment. I understand that even if I suspend or terminate treatment, any fees for professional services rendered to me or to my dependent up to the point of termination will be immediately due and payable.

I acknowledge that I am responsible for any outstanding fees for services provided to me by New You Health Partners, LLC  (“Practice”).

Any other arrangements that may involve a payment plan or payment deferral must be made in writing with the office manager or business manager of the Practice. Verbal agreements are not acceptable.

Patient Consent for Photography

I, as the patient identified above or the legal representative of such patient (“Patient”), consent to have photographs, videotapes, digital or audio recordings, and/or images of the Patient, and any other method to reproduce or edit such Patient’s likeness or image now known or hereafter developed (collectively, “Photography”), taken by New You Health Partners, LLC and its staff (collectively “Practice”). I understand that such Photography will be recorded to document and assist with the Patient’s care and to assist with Practice’s health care operations.

I understand that the Photography or a portion of the Photography may become part of my medical record and therefore be protected, used and/or disclosed in accordance with Practice’s Notice of Privacy Practices. I further understand that Practice will own the Photography and I will not receive any payment for such Photography, but that I will be allowed to access or view the Photography or to obtain copies of any portion of the Photography that becomes part of my medical record.

Patient Consent to Treatment

PLEASE READ EACH SECTION CAREFULLY. YOU MAY REQUEST A COPY OF THIS FORM FOR YOUR OWN RECORDS

I, the undersigned, do hereby request and consent to an evaluation and treatment by New You Health Partners and its staff (“Practice”). I wish to rely on the Practice to exercise judgment for my best interest, the below-named patient, during the course of treatment. I will inform the Practice of any sensitive areas or adverse conditions that I may have had prior to, during or after treatment. I intend this consent to cover the entire course of treatment.

I understand that any questions I may have regarding the potential side effects, complications, treatment or treatment area may be directed to the attending Practice staff member during my evaluation and course of treatment.

I understand that the practice of medicine and surgery is not an exact science. I further understand and accept that fees are paid for performance of medical services only, and not a guaranteed result. I acknowledge by my signature below that although a good outcome is expected, and a reasonable effort has been made to establish realistic expectations, there cannot be any warranty, expressed or implied, as to the results that may be obtained.

I request and consent to be transported by Practice staff and/or emergency medical services to a hospital or emergency medical facility in the event of a medical emergency during the course of my treatment at the Practice.