Dr. Willett's Weight Loss Program
5 B East Owens Lane, Mauldin, SC 29662
864-288-4765
Welcome to My Healthy Eating 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 taken:_______________
If Yes, what is the name of the Doctor or Facility?_______________________Date last seen?______________
Name and phone number of your Preferred Pharmacy:_____________________________________________
How did you hear about the program?__________________________________________________________
List any current/chronic conditions that may prevent you from taking weight loss medications (ex. High B/P;
heart problems)____________________________________________________________________________
_________________________________________________________________________________________
REQUIREMENTS FOR THE WEIGHT LOSS PROGRAM
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You must have a BMI of equal to or greater than 25.
Weight loss should be consistent and appointments must be kept.
You MUST have a Valid South Carolina Driver's License (We DO NO accept ID cards.)
You must be compliant with my recommendations.
AUTOMATIC DISMISSAL FOR THE FOLLOWING REASONS
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You are receiving weight loss medication from more than one physician.
Your name is given as someone who is reselling medications, whether true or not.
You do not keep your appointments or cancel your appointments repeatedly.
You do not consistently lose weight.
Any known drug related charges that are brought to our attention.
NO EXCEPTIONS TO THE FOLLOWING:
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.
It is illegal in South Carolina 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 as an appetite suppressant may cause you to test positive for amphetamines. Dr. Willett
is happy to provide a letter of explanation if you have received medications within 30 days from my office.
I understand weight loss medications may have side effects and I 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 this weight loss program and I desire to participate.
SIGNATURE_____________________________________________DATE_______________________
David P. Willett, MD
P O Box 1004, Suite 5-B East Owens Lane, Mauldin, SC 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 )
EMAIL to receive office promotions ____________________________________________________________
SOCIAL SECURITY # _____-_____-_____ DOB ____/____/_____
PRIMARY PHONE # (___)_____-______
CELL PHONE # (____) _____-______ WK # (____)_____-_______
EMPLOYER ____________________ EMPLOYER ADDRESS: ____________________________________
FT OR PT ________
EMERGENCY CONTACT PERSON: ________________________________________ CONTACT # _________________________ RELATIONSHIP ________________
GUARDIAN’S NAME: ___________________________________________/ RELATIONSHIP TO MINOR __________________ LIVING WILL? Y or N
(CHILDREN UNDER 18)
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NAME OF PHARMACY COMMONLY USED: ______________________ PHARMACY PHONE NUMBER ________________
ALLERGIES TO MEDICATIONS: _________________________________________________________
DO YOU SMOKE? _______ if so, ( cigs, cigar, pipe, etc.) How much? ____________
DRINK ALCOHOL? _____ HOW MUCH? ________ TAKE ILLEGAL DRUGS? ________ WHAT? _________________
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 AND ALLOW RELEASE OF MY MEDICAL RECORDS.
SIGNATURE OF PATIENT / GUARDIAN: ____________________________________ DATE _____/______/______
“WELCOME TO OUR OFFICE. IF YOU NEED ME AFTER HOURS, PLEASE CALL 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 REFILL MEDICATIONS 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 any
of our office staff regarding HIPAA Compliance.
Signature below is only acknowledgement that you have received information of this Notice of our Privacy Practices:
Print Name_____________________________ Signature __________________________Date____________
By law, Dr. Willett must inform you that he is not a Medicare / Medicaid provider. It is your responsibility to inform
our office if you are covered by Medicare or Medicaid. You CANNOT file your own claim to Medicare / Medicaid.
Patients will not be paid for any services rendered by David P. Willett, MD.
Signature of acknowledgement________________________ Initial if NOT covered by Medicare or Medicaid _____________