New Patient Forms
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Email
*
Phone Number:
*
Format: (000) 000-0000.
Sex:
*
Please Select
Male
Female
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
Occupation / Job Title
How did you hear about us?
Internet Search
Social Media
Friend / Patient Referral
Magazine
TV / Infomercial
Billboards
Newspaper
Radio
Other
Referral:
Please enter the full name of who referred you.
Emergency Contact:
*
First Name
Last Name
Relationship
*
Contact Number
*
Format: (000) 000-0000.
Please Upload a Photo/Copy of Your Driver's License:
*
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Medical History
DIAGNOSES: Please select if you have been diagnosed or treated for any of the following:
None
Overweight/Obesity
Pancreatitis
High Cholesterol /Triglycerides
Multiple Endocrine Neoplasia 2 (MEN2)
Diabetes Mellitus / Prediabetes
AIDS/HIV Positive
Alcoholism
Anemia
Anorexia
Arthritis
Bleeding Disorders
Chronic Bronchitis
Bulimia
Cancer
Celiac Disease
Chemical Dependency
Emphysema
Epilepsy / Seizures
Glaucoma
Goiter
Gout
Heart Disease
Hepatitis
High Blood Pressure
Kidney Disease
Migraine Headaches
Multiple Sclerosis
Pacemaker
Psychiatric Disorders
Stroke
Suicide Attempt
Thyroid Problems
Tuberculosis
Ulcer
PCOS
Metabolic Syndrome
Gastroparesis
Obstructive Sleep Apnea
Fatty Liver Disease
Type of Cancer:
*
Are you post-menopausal?
*
No
Yes
When was your last menstrual period?
*
-
Month
-
Day
Year
Date
Are you pregnant or currently trying to conceive?
*
No
Yes
Not Sure
Do you currently take an oral contraceptive or have an IUD?
*
Yes
No
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Surgery & Hospitalization History
Have you had liposuction in the past?
*
Yes
No
What year(s) did you have liposuction?
*
What area(s) did you have treated? Select all that apply.
*
Abdomen
Arms
Back
Buttocks
Chin
Knees
Love Handles / Flanks
Male Chest
Inner Thighs
Waist / Hips
Other
Have you had any hospitalizations or other surgeries?
Yes
No
Please list the reason(s) for hospitalizations/surgeries, dates, and hospitals below:
Have you ever been pregnant?
*
Yes
No
PREGNANCY HISTORY: Please list the year of each pregnancy, outcome / type of delivery:
(i.e. 2015 - C-Section)
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Family History
Please select if you have a family history of any of the following:
*
None
Obesity
Cancer
Chemical Dependency
Diabetes
Heart Disease, Strokes
High Blood Pressure
Elevated Cholesterol / Triglycerides
Medullary Thyroid Cancer
Multiple Endocrine Neoplasia 2 (MEN2)
Other
Please list the conditions selected and their relationship to you:
*
(i.e. High Blood Pressure - Father)
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Health Habits
Do you consume caffeine?
*
Yes
No
Caffeine consumption (drinks per day)
*
Do you use tobacco?
*
Yes
No
Tobacco use (packs per day)
*
How often do you consume alcohol?
*
Never
1-2 per week
3-5 per week
5+ per week
Illicit Drug Use
*
Yes
No
Please describe usage:
Drug/Frequency
Weight History
What is the highest you have weighed (lbs)?
*
What age were you at your highest weight?
*
Which of the following have you tried in the past for weight loss?
*
Dieting
Exercise
Coaching
Medications
Which weight loss medication(s) have you tried in the past?
*
Semaglutide (Ozempic / Wegovy)
Phentermine (Adipex)
Tirzepatide (Mounjaro)
Other
Please upload a photo or copy of your past weight loss medication prescription if available:
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What diets have you tried?
*
Weight Watchers
Low Carb / Keto
Intermittent Fasting
Macros / Calorie Counting
Other
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Medications
Preferred Pharmacy:
*
Pharmacy Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please List All Medications and Supplements:
Rows
Medication
For What?
Date Stopped?
1.
2.
3.
4.
5.
6.
Any known drug allergies?
*
No Known Drug Allergies
Yes
Drug Allergies:
*
Rows
Drug
Symptoms/Reactions
1.
2.
3.
4.
Any known food allergies?
*
No Known Food Allergies
Yes
Food Allergies:
*
Rows
Food
Symptoms/Reactions
1.
2.
3.
4.
I certify that the information provided in this form is correct & complete to the best of my knowledge. I will not hold my doctor or any member of the staff responsible for errors or omissions that I may have made on this form.
*
Yes, I certify.
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Consultation Video
Please watch this video prior to your consultation (required):
I acknowledge that I have watched the above video in full.
*
Yes, I have watched the video.
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Consents & Acknowledgements
CONSENT TO TREAT - I, the undersigned, hereby voluntarily consent and grant permission to J Bergeron MD PA, physician and employees to perform tests, treatments and any procedures as indicated at J Bergeron MD PA for myself or the above named minor, for as long as I am a patient at J Bergeron MD PA.
*
Yes, I consent
CONSENT TO EMAIL LAB RESULTS - I consent to receiving my lab results via email at the above email address. I understand that my full name and date of birth will be listed on the results.
*
Yes, I consent
OCCUPATIONAL HAZARD - In the event of an injury (i.e. needle stick) to an employee, that exposes any of my bodily fluids, at J Bergeron MD PA premises, I, the undersigned, hereby voluntarily consent to give a blood specimen for testing.
*
Yes, I consent
RECORDING DEVICE POLICY - The use of recording devices is strictly prohibited. This includes mobile phones, cameras, smartwatches, laptops, tablets, and camera-enabled eyewear. No audio, video, photographic, or live recording or transmission of patients, procedures, or clinical areas is allowed. Unauthorized recording may result in disciplinary action, removal from the area, and possible legal consequences. All patients, staff, trainees, vendors, and visitors must follow this policy at all times
*
Yes, I acknowledge
Notice of Privacy Practices:
ACKNOWLEDGEMENT: REVIEW NOTICE OF PRIVACY PRACTICES & PATIENT RIGHTS - I have reviewed this office's Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.
*
Yes, I acknowledge
Signature
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