ambitiousbranding.comambitiousbranding.com/mwlocs2/patient.docx · Web viewFALSE. The only proven way to lose weight is either to reduce the number of calories you eat or to increase

Cynthia E. Collins, MD100 Covey Drive, Suite 107

Franklin, TN 37067615-771-8753

www.mwlocs.com

WEIGHT LOSS HCG TREATMENT

PATIENT

INFORMATION

PACKAGE

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Franklin, TN 37067615-771-8753

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“MEDICAL WEIGHT LOSS OF COOL SPRINGS (MWLOCS) WILL HELP IMPROVE THE HEALTH OF THE BODY GOD HAS GIVEN. WE WILL PROVIDE THE KNOWLEDGE, MEDICATION INSTRUCTIONS, DIET AND EXERCISE INFORMATION TO ASSIST YOU ON YOUR WEIGHT LOSS JOURNEY. IT IS OUR HOPE THAT AFTER REACHING YOUR DESIRE WEIGHT LOSS GOAL, YOU WILL CONTINUE TO STRIVE FOR A HEALTHIER YOU AND MAKE GOOD LIFESTYLE CHOICES.” CYNTHIA E. COLLINS, MD, CEO OF MEDICAL WEIGHT LOSS OF COOL SPRINGS.

The Facts about Weight Loss

Being obese can have serious health consequences. These include an increased risk of heart disease, stroke, high blood pressure, diabetes, gallstones, osteoarthritis, sleep apnea, depression, some forms of cancer and more. Losing weight can help reduce these risks. Here are some general points to keep in mind:

Any claims that you can lose weight effortlessly are usually FALSE. The only proven way to lose weight is either to reduce the number of calories you eat or to increase the number of calories you burn off through exercise. Most experts recommend a combination of both.

Very low calorie diets are not without risks, and should be pursued only under medical supervision. Unsupervised very low calorie diets can deprive you of important nutrients and are potentially dangerous.

Fad diets rarely have any permanent effect. Sudden and radical changes in your eating patterns are difficult to sustain over time. In addition, so called “crash” diets often send dieters into a cycle of quick weight loss, followed by a rebound weight gain once normal eating resumes, and makes it even more difficult to lose weight when the next diet is attempted.

The complications of wt loss are: headaches, dizziness, low blood pressure, low glucose, constipation, gallstones, kidney stones, and others. MWLOCS will follow the patient closely to avoid unwanted complications.

To lose weight safely and keep it off requires long-term changes in daily eating and exercise habits. Many experts recommend a goal of losing about a pound a week. A modest reduction of 500 calories per day should achieve this goal, since a total reduction of 3,500 calories is required to lose a pound of fat. An important way to lower caloric intake is to practice healthy eating habits.

Sensible Weight Loss Tips

Losing weight may not be effortless, but it doesn’t have to be complicated. To achieve long-term results, it is best to avoid quick fix schemes and complex regimens. Focus instead on making modest changes to your life’s daily routine. A balanced, healthy diet and sensible, regular exercise are the keys to maintaining your ideal weight.

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Although nutrition science is constantly evolving, here are some generally accepted guidelines for losing and maintaining weight loss.

Here are 13 simple Tips for general Weight Loss:

1. Weight Loss Daily Routine - awaken with bathroom trip, weigh yourself, then take wt loss treatment. (don’t forget to shout when wt drops)

2. H2O like a Pro - drink plenty of water throughout your day to take the edge off hunger and it hydrates you. Drink half your weight in ounces daily.

3. Doggie Bag it - when out at a restaurant take half of your serving of food home to lessen your calories.

4. BYOL - Bring Your Own Lunch to work or school and avoid the fast food invitations.5. Your Plate - should be ½ cooked foods and ½ uncooked (raw) foods. Don’t go back for

seconds, decrease portions and consider eating on a salad plate. Your plate should look like a rainbow.

6. Pantry Makeover - remove high calorie foods from your pantry, such as high fructose corn syrup foods. No can goods on wt loss program.

7. Close the Kitchen- turn out the lights after meals, the more you go into the kitchen the more likely you will be tempted to eat.

8. Burn the Fat- exercise your body 30 minutes per day. Move around in your daily life, park away from store doors, do active choices (mopping, vacuuming, yard work, etc…).

o Reach your target heart rate while exercising (if medical able).o 220-your age= Maximum Heart Rate (Max HR)o Take that # in two ways for your upper and lower limitso Max HR x 60%= lower range limit and Max HR x 80%= upper range limito This is the range for burning fat

9. Power of Sleep- proper sleep 6-8 hours per night is needed for weight loss.10. Keep a Food Diary- write down what you eat to stay on track.11. Eat Breakfast- so you don’t overeat later, eat 3 meals a day, and stop eating 3hrs before

bedtime.12. Tackle emotional eating- feeling angry, sad or bored can make you eat so keep health snacks

on hand.13. Manage stress- help yourself relax by taking 10 minutes for deep breathing while counting

your Blessings! Our God loves Praises!

Avoid or lessen these five items to loss and maintain weight loss:

1. Breads

2. Sweets3. Potatoes4. Noodles

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5. Rice

THE HISTORY OF HCG

Human Chorionic Gonadotropin, or HCG, is a natural human hormone produced by the placenta of pregnant women. One of the purposes of HCG during pregnancy is to ensure tl1e growing baby has a constant and steady supply of energy and nutrients by mobilizing the reserves stored in the mothers' adipose (fat) tissue.

The original HCG protocol for weight loss was developed by Dr. A.T.W. Simeons of Salvador Mundi International Hospital, in Rome, Italy, in the 1950's and 60's. Dr. Simeons realized that regularly limed small doses of HCG in the average person, men and women who are not pregnant, would have the same effect, mobilizing approximately 2000 calories worth of stored energy, or 1pound of body fat, making it available for use by the body. During the 1970's, it was one of the most popular weight loss programs in the United States, and is now seeing resurgence in popularity.

THE BENEFITS OF HCG

With HCG, your body has a constant and steady supply of energy. This keeps you from feeling hungry, tired, weak, or irritable. HCG also improves your metabolism. When dieting without HCG, and especially when eating only a couple of meals per day, your body thinks you are starving, your metabolism slows down, you become hungry all the time, and your body begins to store any calories it may get because it does not know when the next meal will come or if it will be big enough to satisfy its nutritional requirements. In addition, when you are done dieting without HCG, your body stays in that defensive mode of increased hunger, decreased metabolism, and storing all the calories it can until you have gained back all the weight you have lost and sometimes more. It does this as a precaution in the event that you should ever "starve" again, or in other words, go on another diet.

This does not happen with HCG. On the HCG weight loss program of Medical Weight Loss of Cool Springs, a natural hormone is telling your body to mobilize and utilize its own reserves, filling the blood stream with a constant supply of energy and nutrients. This enables you to diet safely and comfortably lose up to a pound or more every day until you reach a healthy weight.

REAL HCG

We only use the real injectable HCG (PREGNYL) produced by American FDA regulated companies. Homeopathic drops DO NOT contain real Human Chorionic Gonadotropin. They are mixtures of supplements which are claimed to mimic the effect of real HCG. However, no supplement, whether it is a vitamin or herbal remedy, or homeopathic HCG, is required to obtain FDA approval or testing. When you purchase any supplement, you do so at your own risk and no supplement can truly mimic the effect of a natural human hormone.

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PHASES OF HCG DIET EXPLAINED: Phase 1 (Gorging, Injections Begin) refers to the first two days of the diet itself while starting the intake of HCG. These are the "gorge" days where on e eats on very high fat foods. Example: avocados, cheeses, heavy cream sauces etc. Two reasons for this phase are noted: One is to alert the body that extra fat calories need burning, so start those engines. Another is that this relieves any hunger and other discomfort i n the first week of the diet.

Phase 2 (Diet Begins) starts the intake of the very low caloric diet (VLCD) o f 5 0 0 c a l o r i e s and can r u n for 20 to 40 days depending on the amount of weight loss desi red. The VLCD is specific in the terms of how and what to eat (see sample customized diet) and the VLCD continues for another three days into the maintenance phase.

Phase 3 (Weaning) is also known as the maintenance phase which runs 3 weeks before starting another cycle and going back to Phase 1 "gorging". Ad d one week to Phase 3 each time it is done. It is a continuation of Phase 2, except that the caloric intake is onl y 100 calories more a day for the first five days after your last injection day. This is important for recalibrating the body's weight set point. If ones gains 2 pounds above the last Phase 2 weight one should do a "steak day" involving no breakfast or lunch then eating the l a rgest steak you can find for dinner followed by an apple.

Phase 4 (New Lifestyle) is the choices you make for the rest of your life. The majority of those who have completed the HCG diet as recommended do not regain the weight loss. This may be due to a combination of a reset metabolism and lifestyle cha nges adopted during the diet.

HIGH IMPACT EXERCISE IS NOT RECOMMENDED DURING THE HCG DIET. LOW IMPACT WALKING ON TREADMILL, IN MALLS, OR WITH PET IS SUGGESTED.

*Please avoid going to the internet for answers on your diet. The MWL HCG Diet is customized based on literature review and clinical experience. If you have any questions please call Medical Weight Loss of Cool Springs.

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Dr. Collins & Vicki Yohe’s

Customized HCG Diet

Day 1 Breakfast:

Coffee, Tea (hot or cold), water Sweetened with Stevia ONLY or plain

Day 1 Lunch:

3oz Sirloin steak (159 calories) grilled or baked, see seasonings in Hints list 10 medium Asparagus spears (30 calories) 3 cups Lettuce (15 calories) with 2 Tablespoons non-fat Italian dressing (15

calories)- Kroger brand suggested

Day 1 Snack:

1/2 grapefruit (44 calories)

Day 1 Dinner:

Chicken breast 3.25 oz (suggested Tyson grilled and ready fully cooked- 110 calories)

3 cups Spinach (21 calories) Standard salad – leafy greens, tomato, and cucumber (30 calories)

Day 1 Snack (2 nd ):

2 Grissini breadsticks (40 calories) 5 medium Strawberries (20 calories)

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Dr. Collins & Vicki Yohe’sCustomized HCG Diet

Day 2 Breakfast:


Day 2 Lunch:

Shrimp salado 4 cups Lettuce (20 calories) with 2 Tablespoons non-fat Italian dressing

(15 calories)- Kroger brand suggested Large Orange (86 calories)

Day 2 Snack:

2 Melba Toast (24 calories)

Day 2 Dinner:

3oz Sirloin Steak (159 calories) 1 cup of Cabbage (22 calories) Standard salad (30 calories)


½ cup raw Blueberries (42calories)

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Franklin, TN 37067615-771-8753

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Dr. Collins & Vicki Yohe’sCustomized HCG Diet

Day 3 Breakfast:


Day 3 Lunch:

Chicken breast 3.25 oz (suggested Tyson grilled and ready fully cooked- 110 calories)

3 cups Asparagus (30 calories) Standard salad (30 calories) ½ grapefruit (44 calories)

Day 3 Snack:

1meduim Apple (95 calories)

Day 3 Dinner:

Tilapia 3oz (96 calories) 3 cups Spinach (21 calories) Standard salad (30 calories)


Strawberries 10 medium (40 calories)

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Franklin, TN 37067615-771-8753

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Customized HCG Diet

Day 4 Breakfast:


Day 4 Lunch:

Sirloin Steak (159 calories) Broccoli ½ cup (15 calories) Standard salad (30 calories)

Day 4 Snack:

Large Orange (86 calories)

Day 4 Dinner:

Flounder 4oz (100 calories) 1 cup cabbage (22 calories) 1 medium tomato (22 calories) Standard salad (30 calories)


2 Melba Toast (24 calories)

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Customized HCG Diet

Day 5 – Choose any menu from Day 1-4

(Please review list of approved vegetables, fruits, meats, fish, etc…)

Helpful Hints (Please review):

Water intake per day should be ½ bodyweight in ounces , ex. 200 pounds would equal 100 oz of water/day

To help with the sweet tooth you can chew sugar free gum Standard salad= leafy greens, tomato and cucumber with 2 tablespoons of dressing Only 2 fruits per day, eating more will decrease wt loss Only 2 Melba Toast or Grissini breadsticks per day, eating more will decrease wt loss Meats must be broiled, baked, grilled with no fat added, trim visible fat Steam, grill, boil, or bake vegetables Seasonings use the following- lemon juice, pepper, garlic, sweet basil, thyme,

marjoram, cinnamon, small amount of salt (sea salt preferred) Change meats between lunch and dinner, if possible Prepare meats in advance for your meals Remember- palm of hand is size of protein (meats), thumb is tablespoon, and fist is a

cup A great way to keep track of your calories is to download the MY Fitness Pal app onto

your phone or other wt loss apps. Join our Facebook page – Medical Weight Loss of Cool Springs for encouragement and

meet other HCG patients.

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HCG Food List (ounces):

FRUITS: one fruit per meal, do not mixApple- medium (95)Grapefruit ½- (44)Orange- large (86)Strawberries- 10 medium (40)Blueberries- ½ cup (42)

STARCH:Melba Toast- 1 (20)Melba Snack- 2 (24)Grissini Breadstick- 1 (20)

MEATS: 3 ½ oz, fat removed, weighted raw, cooked in no oil or fatChicken Breast-(110)Ground Beef,95% Lean- (137)Steak (round/sirloin tip)- (142)Crab- (84)Halibut- (110)Cod- (110)Flounder- (91)Tilapia- (96)Lobster- (90)Shrimp- (106)Veal- (112)

VEGETABLES: measured raw, adjust serving size to fit your 500 calories per dayAsparagus- 10 medium spears (30)Beet-Greens (24)Cabbage- 1 cup (22)Celery- 2 cups (32)Chard- 3 cups (21)Cucumber- 1 medium (45)Fennel- 1 cup (27)Lettuce- 3 cups (15)Onion- 1/2 cups (32)Red Radishes- 1 cup sliced(19)Spinach- 3 cups (21)Tomatoes- 1 medium (22), 1 cup (27)

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Milk- 1 Tablespoon whole milk (9 calories)

HCG Maintenance Phase (3wks): 10 Basic Rules

1. Increase Calories- increase caloric intake 100 calories per day for 5 days, then increase or decrease based on weight loss or gain. Estimated max calories per day is 1000- 1200, but consider Resting Metabolic Rate Testing offered at MWLOCS for more exact count of daily required caloric intake.

2. Weight Daily- the goal is to stay within 2 pounds of your weight at the time of the last HCG injection. Gaining or losing more than 2 pounds will reset your weight clock.

3. No sugar/No Carbohydrates- continue eating the same foods, simply increase calories.

4. Fats & Dairy- non-processed cheese, sugar- free yogurt can be used5. Drink Water- ½ your wt in ounces6. Protein- lean, organic but no pork7. Steak Day- if your wt goes over 2 pounds from the last injection a steak day is

required- skip breakfast and lunch, then eat the largest steak you can eat for dinner, followed by an apple. Optional Apple Day- no breakfast then 6 apples from lunch to lunch and water to drink.

8. Workout- resume regular exercise regiment gradually, 30 minutes 3x week to 5x week

9. No restrictions – on lotions, oils, or beauty products10.Congratulations!!!!!!!!!!

Enjoy the fabulous new you!

Thanks for making the Medical Weight Loss of Cool Springs your choice for weight loss management. God has blessed MWLOCS with an anointing for weight loss. May God Blessings be upon you and we

are praying for your success!!!

www.mwlocs.com

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Frequently Asked Questions (FAQ) about HCG Diet:What is the history of the HCG diet?

Dr. A.T.W Simeons of Salvador Mundi International Hospital in Rome, Italy introduced the original HCG diet in the 1950’s and 1960’s.

Dr. Simeons discovered the combination of a restricted calorie diet with the introduction of small doses of HCG in the average NON-pregnant person would mobilize approximately 2000 calories of energy or 1 pound of body fat.

During the 1970’s the HCG diet became one of the most popular weight loss program in the United States.

What is HCG?

HCG or Human Chorionic Gonadotropin is a naturally occurring hormone produced by the placenta during pregnancy.

How does HCG work?

HCG’s natural functions during pregnancy include protecting the ovaries, maintaining progesterone levels, increasing immune tolerance, and mobilizing fat.

During pregnancy, HCG supports the growing baby with energy by mobilizing nutrients stored in the mother’s adipose (fat) tissue.

HCG biochemically targets fat stores around the hips, thighs, abdomen and upper arms.

What is the difference between the injections and the drops?

We only use the real injectable HCG (Pregnyl) produced by an American FDA regulated company.

The homeopathic drops DO NOT contain the real HCG hormone. The drops are a mixture of supplements that can only mimic the effects of the

real natural human HCG hormone.

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Frequently Asked Questions (FAQ) about HCG Diet (cont’d):

How much weight will I lose?

The average HCG dieter will lose about ½ to 1 pound per day.

Who is eligible for HCG weight loss injections?

Men and women are both eligible for weight loss with the HCG injection diet. The same HCG hormone used in the injection is already present in the tissue of

both men and women. The low dose of HCG used in the diet has virtually no side effects in men or

women. Pregnant or nursing women are NOT eligible candidates. Dr. Collin’s will determine an individual’s eligibility for HCG injections.

What are the benefits of HCG injections? Average weight loss from ½ to 1 lb per day Decreased hunger and Increased Metabolism Increased libido in men and women No loss of muscle or structural fat Decrease in excess fat and stored fat Maintaining weight loss despite returning to a regular calorie diet

Is it safe to use HCG injections for weight loss? Yes. Although HCG has not been specifically approved by the FDA for weight

loss, it has been FDA approved for the treatment of many other medical conditions such as infertility.

The dosages of HCG used for weight loss produces little or no side effects.

Is a very low calorie diet necessary? Yes. It is important to create a caloric deficit within the body. The HCG hormone will not be induced to mobilize the fat stores and burn them

for energy if there is no decrease of calories coming into the body. The typical HCG dieter should limit their caloric intake daily to 500 for the

best wt loss or extend to 700 calories if needed due to symptoms but will not see the best wt loss.

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Dr. Collins can help guide if a higher daily caloric intake is needed.Frequently Asked Questions (FAQ) about HCG Diet (cont’d):

Will I be hungry on a 500-700 calorie diet? Most HCG dieters report little to no increase in hunger when receiving the

injections. HCG has an effect on your hypothalamus gland helping to decrease your food

cravings and reset your metabolism.

What seasonings can be used? Salt preferably sea salt(sparingly), pepper, and natural herbs

What are the possible side effects? Mild Headache, May increase frequency of migraine headaches Constipation due to diet change, but drink the required fluids Mild dizziness Irregular Menses Occasional Bruising

Are there any Adverse Reactions? (RARE) Allergic reaction to HCG Edema to ankles/feet Development of Ovarian Hyper-stimulation Syndrome (OHSS)

Will I plateau? There is chance you may plateau around weeks 3 and 4, one possible reason is

constipation. You can use over the treatment to relieve this problem. Other reasons for plateau can be discussed with Dr. Collins

What if I went off the diet plan? If you went off the plan for a day you can recover by taking a “Steak Day”. Skip

breakfast, lunch and only water to drink, then for dinner eat the largest steak available and an apple.

If a steak day doesn’t work, then do an “Apple Day” which consists of no breakfast then 6 apples from lunch to lunch and water to drink. This can get your weight loss back on track.

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Patient Information:

Name: ________________________________________________________________________________ Date: __________________________

Age: _________________ Sex: Male / Female 1. Are you in good health at the present time to the best of your knowledge?

Yes No (If no, Explain) __________________________________________________________2. Are you under a doctor’s care at the present time?

Yes No (If yes, for what?) ________________________________________________________3. Are you currently dieting?

Yes No (If yes, describe) ________________________________________________________Medical History:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Prescription Drugs: (List all)Drug Dosage Drug Dosage______________________________________________________ _________________________________________________________________________________________________________________________ ___________________________________________________________________ ______________________________________________________ ___________________________________________________________________

Over-the-Counter medications, vitamins, supplements: (List all)Product Dosage Product Dosage______________________________________________________ ___________________________________________________________________ ______________________________________________________ ___________________________________________________________________

Allergic to any medications?Medication Allergic Reaction_____________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ __________________________________________________________________

Serious Injuries or Surgeries: (List all)Date Injury/Surgery__________________ _________________________________________________________________________________________________________________ _______________________________________________________________________________________________ __________________ _______________________________________________________________________________________________

Women Only:Date of Last Menstrual Period: _____________________ Age at onset of menstruation: __________________________Are your periods irregular, painful, or heavy? (If yes, please explain) ___________________________________________________________________________________________________________________________________________________________________Number of pregnancies: ____________________________ Number of children: _______________________________Are you pregnant, trying for pregnancy, or breast feeding? Yes No

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Patient Information (cont’d):

Health History: (check all that apply)_____ Dizzy Spells _____ Blood Transfusion _____ Epilepsy_____ Convulsions _____ Psychiatric Problems _____ Pleurisy_____ Kidney Disease _____ Diarrhea _____ Liver Disease_____ Lung Disease _____ Eating Disorder _____ Glaucoma_____ Rheumatic Fever _____ Bleeding Disorder _____ Gout_____ Ulcers _____ Nervous Breakdown _____ Cancer_____ Anemia _____ Heart Valve Disorder _____ Heart Disease_____ Tuberculosis _____ Gallbladder Disorder _____ Insomnia_____ Drug Abuse _____ Frequent Headaches _____ Shortness of Breath_____ Alcohol Abuse _____ Vascular Disease _____ Pneumonia_____ Constipation _____ Thyroid Disease _____Irregular Pulse_____ Arthritis _____ Osteoporosis _____ Nervousness_____ Migraines _____ Moodiness _____ Arrhythmia _____Palpitations _____Hyperthyroidism _____ Hypothyroidism_____High Blood Pressure _____Diabetes _____Other:______________

Has any relative ever had any of the following?:Glaucoma Y N Relation______________________________________ Asthma Y N Relation______________________________________Epilepsy Y N Relation _____________________________________High Blood Pressure Y N Relation _____________________________________Kidney Disease Y N Relation _____________________________________Diabetes Y N Relation _____________________________________Psychiatric Disorder Y N Relation _____________________________________Heart Disease / Stroke Y N Relation _____________________________________

Activity Level: (answer only one)____ Inactive- no regular physical activity____ Light Activity- occasionally involved in activities such as walking, weekend golf,

tennis, jogging, swimming or cycling____ Moderate Activity- consistent lifting, stair climbing, heavy construction, etc., or

regular participation in walking for more than 35 minutes, jogging, swimming, cycling or active sports at least three times per week

Behavior Style: (answer only one)____ I am always calm and easygoing. ____ I am usually calm and easygoing.____ I am sometimes calm and easygoing.____ I am seldom calm and persistently driving for advancement____ I am never calm and have overwhelming ambition____ I am hard-driving and never relax.

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Weight History:

Name: ____________________________________________________________________ Date: ____________________________________

1. What is the main reason you decided to lose weight? ___________________________________________________

____________________________________________________________________________________________________________________

2. When did you begin gaining excess weight? ______________________________________________________________

____________________________________________________________________________________________________________________

3. What do you think is the main cause of your weight problems? _______________________________________

____________________________________________________________________________________________________________________

4. Describe your previous attempts at weight loss: _________________________________________________________

____________________________________________________________________________________________________________________

5. Is your spouse/fiancé/partner overweight? Yes No

6. How often do you dine out? Where? What type of food? ________________________________________________

____________________________________________________________________________________________________________________

7. What is your typical breakfast/lunch/dinner? ___________________________________________________________

____________________________________________________________________________________________________________________

8. List any food allergies. ________________________________________________________________________________________

____________________________________________________________________________________________________________________

9. What foods do you crave? ____________________________________________________________________________________

____________________________________________________________________________________________________________________

10. What foods do you avoid? ____________________________________________________________________________________

____________________________________________________________________________________________________________________

11. Do you awaken hungry during the night? Yes No

12. What are your worst food habits? __________________________________________________________________________

____________________________________________________________________________________________________________________

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Weight History (cont’d):

13. What are your snack habits? ________________________________________________________________________________

____________________________________________________________________________________________________________________

14. Rate your body from 1 to 10. How would you describe your body?

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

15. If you could change one thing about your body, what would it be?

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

16. What do you feel will be your main obstacle to successful weight loss?

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

17. Rate your salt intake: High Medium Low

18. Rate your fat intake: High Medium Low

19. Rate your caffeine intake: High Medium Low

20. Do you drink alcohol? If yes, what type (wine, beer, liquor)? __________________________________________

How often do you drink alcohol? ___________________________________________________________________________

21. Do you smoke tobacco? Yes No How many packs per day? ____________________________________

How long have you smoked?

_________________________________________________________________________________

22. Additional information that would be beneficial to the doctor:

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

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PATIENT INFORMATION

NAME: _______________________________________________________________SSN: _________-_________-_________

DATE OF BIRTH: ____________________________________SEX: M F MARRIED: Y N

ADDRESS: _______________________________________________________________________________________________

CITY: ______________________________________________STATE:_______________________ZIP:_________________

HOME (_______) _______________________________________CELL (_______) _________________________________

EMAIL: __________________________________ HOW DID YOU HEAR ABOUT US? __________________________

EMERGENCY CONTACT: ______________________________________ PHONE #: (_____) _____________________

RELATION: ___________________________________________________________________________________________

INSURANCE INFORMATION

Medical insurance policies do not typically cover weight management care and related services. With the primary diagnosis of Obesity/Overweight, the Medical Weight of Cool Springs requires payments by cash/credit/debit only. Payments are non-refundable however credit balances can be transferred to a different weight loss treatment program. An appropriate receipt of payment will be provided, including charges and descriptions of the office visit for the different levels of service provided. This can be used for flex accounts or other insurance services at the patient’s discretion.

Medical Weight Loss of Cool Springs does offer some additional medical weight loss services that require insurance billing, such as Drug Testing and Resting Metabolic Rate testing that is performed by consent from the patient.

I have read and fully understand the above information related to insurance and participation in Medical Weight Loss of Cool Springs weight loss program. Also, I had the opportunity to ask questions regarding these issues. I am aware that I will receive an appropriate receipt of payment for my personal use as I see fit to do so. I understand the specifics of these receipts and limitations as described in this document. I accept these specific policy rules.

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Patient Signature: ____________________________________________________Date: ______________________

Consent for Use or Disclosure of Health Information

Our Privacy Pledge

We are very concerned with protecting your privacy. While the law requires us to give you this disclosure, please understand that we have, and always will, respect the privacy of your health information.

There are several circumstances in which we may have to use or disclose your health care information. We may have to disclose your health information to another health care provider or a hospital if it is

necessary to refer you to them for the diagnosis, assessment, or treatment of your health condition. We may have to disclose your health information and billing records to another party if they are

potentially responsible for the payment of your services. We may need to use your health information within our practice for quality control or other

operational purposes.

We have a more complete notice that provides a detailed description of how your health information may be used or disclosed. You have the right to review that notice before you sign this consent form. We reserve the right to change our privacy practices as described in that notice. If we make a change to our privacy practices, we will notify you in writing when you come in for treatment or by mail. Please feel free to call us at any time for a copy of our privacy notes.

Your right to limit uses or disclosures

You have the right to request that we do not disclose your health information to specific individuals, companies, or organizations. If you would like to place any restrictions on the use or disclosure of your health information, please let us know in writing. We are not required to agree to your restrictions. However, if we agree with your restrictions, the restriction is binding on us.

Your right to revoke your authorization

You may revoke your consent to us at any time; however, your revocation must be in writing. We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke your authorization. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims.

I have read your consent policy and agree to its terms. I am acknowledging that I have received a copy of this notice.

______________________________________________ ________________________________________ Patient Printed Name Medical Provider Name

______________________________________________ _________________________________________

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Signature/Date Signature/Date

Out of State HCG Program Steps Medical Weight Loss of Cool Springs has extended our services to help people near and far. While participating in our Out of State program we assure quality service to help you during your weight loss journey.

Below are the steps necessary to participate in this program:

Email or fax patient packet with medical form, credit card authorization form and photo ID.

Dr. Collins will review medical information, if approved; your credit card will be charged $399.00 plus shipping ($25 regular priority 2- 4 days or $50 overnight).

You will be called to schedule a Face to Face appointment with Dr. Collins to go over HCG program. You will be sent a secure medical approved link for Face to Face videophone visit, via email. You will need to download and sign into this Videophone system. It works best with iphones, ipads or desktop computers with a camera. If these devices are not available, then a regular phone visit will be used temporarily.

HCG WILL BE SHIPPED OUT WITHIN 10 BUISNESS DAYS OR LESS, from the videophone visit.

Please text or call in your weight once a week and keep a daily log of your wt on our log sheet given.

For questions or problems please contact Dr. Collins at [email protected]

Please send weekly weight to 615-974-8826 or via Email to [email protected]

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mailto:[email protected]


Franklin, TN 37067615-771-8753

www.mwlocs.com

Authorization for Release of Healthcare Information

Patient Identification:

Name: _____________________________________________________________________________________________________________________

Address: ___________________________________________________________________________________________________________________

City, State, Zip: ____________________________________________________________________________________________________________

DOB: __________________________________________________ SS#: (0ptional)___________________________________________________

I hereby authorize and request the release of my records from:

Physician Name___________________________________________________________________________________________________________

Healthcare Facility: _______________________________________________________________________________________________________

Address: ___________________________________________________________________________________________________________________

Phone #: ___________________________________________________________________________________________________________________

Fax #: ______________________________________________________________________________________________________________________

Please send To:

Medical Weight Loss of Cool Springs100 Covey Drive, Suite 107

Franklin, TN 37067615-771-8753 office/ 615-771-8757 fax

_____ Recent Office Visit and Labs ____________________________________________________________ Recent EKG_________________________________________________________________________ Other__________________________________________________________________________

Signature (patient): ______________________________________________________________Date_______________________

(This authorization expires ninety days after it is signed.)

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Franklin, TN 37067615-771-8753

www.mwlocs.com

Patient Medical Form (Please complete all):

Name____________________________________________________Date________________________

Age______________________ Date of Birth______________________________________

Weight________________lbs Height_________ft________inches BMI___________

(BMI will be calculated by MWLOCS if not available)

BP___________/___________ Pulse____________

Lab Test (required):

Urinanalysis______________________________________________Date______________________

Urine pregnancy test (females)_______ LMP______________________

Menopausal ___________yes / no Date of onset________________________________

CBC/CMP/Lipids/TSH/Vitamin D (required) Date_____________________

Labs sent to MWLOCS? Yes / No /Pending____________________________________

Date of last physical ___________________________By__________________________________

Last physical sent to MWLOCS? Yes / No / Pending________________________

Other___________________________________________________________________________________

__________________________________________________________________________________________

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Franklin, TN 37067615-771-8753

www.mwlocs.com

One Time Credit Card Payment Authorization Form

Sign and complete this form to authorize MEDICAL WEIGHT LOSS OF COOL SPRINGSTo make a onetime debit to your credit card listed below.

By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.

Please complete the information below:

I ____________________________________________(full name) authorize MEDICAL WEIGHT LOSS OF COOL SPRINGS to charge my credit card account indicated for _____________(amount) on or after ___________________(date).

This payment is for _____________________________________ (description of services).

Billing Address ____________________________ Phone#________________________

City, State, Zip ____________________________ Email ________________________

Account Type: Visa MasterCard AMEX Discover

Cardholder Name _________________________________________________

Account Number _____________________________________________

Expiration Date _________________________

CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX) ________________

SIGNATURE DATE

I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for

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Franklin, TN 37067615-771-8753

www.mwlocs.com

one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

All information will be secured under our Privacy Agreement!!!

HOW TO MIX YOUR HCG WITH THE BACTERIOSTATIC WATER

Step 1: Supplies:1. One 5ML syringe 2. Only One of your HCG bottle 3. One alcohol wipe4. One bacteriostatic water

Step 2: Take the caps off your bacteriostatic water and your HCG. Next, take your alcohol swipe and clean the gray center of both your HGC and bacteriostatic water.

Step 3: Open your 5ML syringe and take the top off and place it in the center of your bacteriostatic water. Flip your bacteriostatic water with the syringe and pull the handle to the 5ML. Once the syringe is filled up with 5ML of the bacteriostatic water pull out your bacteriostatic water bottle out.

Step 4: Place your 5ML syringe into the center of your HCG bottle. (Do not mix or shake bottle once your bacteriostatic water is in.) Once the bacteriostatic water is mixed with the HCG you have finished with process number 1.

NOTE: Only mix ONE bacteriostatic water with the HCG. Do NOT use both HCG bottles at once. (They will expire at the same time if both turned in to liquid the same day) Once vials are open: PLEASE KEEP REFRIGERATED

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Franklin, TN 37067615-771-8753

www.mwlocs.com

HOW TO DRAW UP AND INJECT YOUR HCG

The supplies you need:

1. 5,000 Units of HCG (In liquid)2. 30 unit insulin syringe3. 2 alcohol wipes4. Empty water bottle

Clean the top center of your HCG liquid with the first alcohol wipe.

Next, you will take your second alcohol wipe and wipe around your subcutaneous layer (One inch from the belly button). You will uncap your syringe and inject your HCG from your knuckle from your belly button. Make sure you pinch the skin and then inject at a 45 degree angle.

Take your 30 unit syringe and pull off the white cap and then uncap the orange cap which is your needle.

You will then inject the syringe in the center of the HCG bottle at a 90 degree angle and draw it up all the way to 25 units.

Once you have injected your HCG discard the syringe into an empty water bottle then cap the bottle and discard.

B-12 Lipoenergetic Wt Management Supplement: Take one capsule twice a day

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Franklin, TN 37067615-771-8753

www.mwlocs.com

If given B-12 injections, then one per week into large muscle (hip or shoulder

Patient wt/vitals charting (please make additional copies as needed):

Date Weight Wt Loss Blood Pressure

Heart Rate

Glucose MWL call

Comments:

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Franklin, TN 37067615-771-8753

www.mwlocs.com

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Documents

ambitiousbranding.comambitiousbranding.com/mwlocs2/patient.docx · Web viewFALSE. The only proven way to lose weight is either to reduce the number of calories you eat or to increase