P O Box 1004, Suite 5-B East Owens Lane, Mauldin, South Carolina 29662 Telephone (864) 288-4765

P O Box 1004, Suite 5-B East Owens Lane, Mauldin, South Carolina 29662 Telephone (864) 288-4765

D a v id P. W i l l e t t, M D

P O Box 1004, Suite 5-B East Owens Lane, Mauldin, South Carolina 29662 Telephone (864) 288-4765

PATIENT INFORMATION SHEET

FULL LEGAL NAME ______SEX: M or F MARITAL STATUS: M S D W

ADDRESS: ______CITY: ______STATE ______ZIP ______

( NO P O BOX )

SOCIAL SECURITY # ____-____-____ DOB ____/_____/_____ EMAIL______

(TO RECEIVE FUTURE OFFICE INFORMATION)

HIPAA APPROVED CONTACTS:______

May our office leave a message at the primary contact phone # below? Yes____ No____

Primary Phone # ( ____) ______Other # (_____) ______-______

EMPLOYER ______Living Will? Y or N

EMERGENCY CONTACT______CONTACT #______-______RELATIONSHIP ______

Guardian’s Name: ______Relationship to Minor ______Guardian’s Contact # (_____) ______-______

(CHILDREN UNDER 18 )

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NAME OF PHARMACY COMMONLY USED: ______PHARMACY # ______-______

ALLERGIES TO MEDICATIONS: ______

Do you smoke? ______If so ( cigs, cigar, pipe, etc.) How much? ______

Drink alcohol? ______How much? ______Take illegal drugs? ______If so, What? ______

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MEDICATIONS TAKEN DAILY AND DOSAGE: (Including over the counter and supplements)

______

______

FAMILY HISTORY OF ILLNESSES: ______

DATE OF LAST TETANUS SHOT: ______(NEEDED EVERY 10 YEARS)

I AUTHORIZE TREATMENT FOR MYSELF BY DAVID P. WILLETT, MD

SIGNATURE OF PATIENT / GUARDIAN: ______DATE _____/______/______“Welcome to our office. If you need me after hours, please call 864-288-4765 and a message will be relayed to me by the hospital answering service. If you need immediate care, go to the emergency room approved by your insurance company and notify our office the next business day. Please request prescription refills during office hours and cancel appointments 24 hours in advance. My staff and I look forward to providing you with excellent quality medical care.”

We are required by law to maintain the privacy of, and provide individuals with this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our office staff regarding HIPAA

DR. WILLETT’S WEIGHT LOSS PROGRAM

P O BOX 1004, MAULDIN, SC 29662

TELEPHONE: (864) 288-4765

Welcome to my weight loss program.

My goal is to help you regain healthy eating habits and improve your physical fitness and health.

Have you ever seen another doctor for weight loss medications? Y or N Medication given ______

If YES, what is the Doctor’s/Facility’s name? ______Last Seen Date ______

Name and Phone Number of Preferred Pharmacy ______

Dr. Willett will not prescribe weight loss medications if you are taking Attention Deficient prescriptions

due to contraindications between weight loss medications & Attention Deficient medications.

______

REQUIREMENTS FOR THE WEIGHT LOSS PROGRAM:

  • You must have a BMI of greater than 25.
  • Weight loss must be consistent and appointments must be kept.
  • You must have a Valid South Carolina Driver’s License. ( We DO NOT accept ID cards OR Passports)
  • You must be compliant with my recommendations.

At the office’s discretion, you may be dismissed for the following reasons:

  • Failure to disclose or update changes in medications including controlled substance medications.
  • Your weight continues to trend upward on the medications.
  • Any known drug related charges that are brought to our attention.

Lost, stolen, or unfilled (unused) Bariatric Medication Prescriptions cannot be refilled before 28-30 days from the original date of the prescription. No money for your office visit will be refunded.

NO EXCEPTIONS!!!

It is illegal in SC to see multiple doctors for weight loss medications during the same period of time. In addition, if your name is given as someone who is selling or abusing medications, whether true or not, you will be terminated from the program.

We will notify DHEC and Crime Stoppers of any illegal use of the controlled substances.

Medications used for an appetite suppressant may cause you to test positive for amphetamines. Dr. Willett is happy to provide a letter of explanation.

I understand weight loss medications may have side effects and will not hold Dr. Willett responsible for adverse reactions as I am voluntarily requesting these medications. I have read and understand the requirements stated above for the weight loss program and desire to participate.

SIGNATURE ______DATE ______