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Thanks for contacting me.

I would like to help you save time, by eliminating stress and paperwork.

Please complete, and submit the Patient Intake. You may choose to print and bring it with you to your appointment.

Please be on time for your appointment. That way we will have more time togeather.

SlenderShot Weight Loss

Dr. Gary Kiefer, ND

Patient Intake

Auburn Way Wellness Clinic
3802 Auburn Way North #301
Auburn, WA 98002
253-886-5016

Lakewood Office
8909 Gravelly Lake Dr. SW
Lakewood, WA 98499
253-584-1144

Your Scheduled Appointment	* Appointment Date	* Appointment Time	* Appointment Location
* Last Name	* First Name	* Middle Initial	* Date of Birth
* Address	* City	* State	* Zip Code
* E-mail	Sex	Person Financially Responsible	May we call you?
* Best Phone	* Best time	Phone	May we leave a message?
Alternate Phone	Best time	Phone	May we leave a message?
Primary Physician	Dr's Address	City	Dr's Phone
Height ft Inch	Current Weight: lbs.	Goal Weight: lbs.	Patient's Age
Allergies?	Meds?	Supplements	Rate your Energy
Exercise Frequency	Exercise Intensity	Smoking?	Alcohol

Typical Diet	Coffee	Standard American Diet	Trying to Change Diet
Vegetarian	Ethnic Diet	Anything I see Diet	McDonald's Diet
Out of Control Diet	Healthy diet	Special Allergy Diet	My Diet
Ounces of water/ day	Ounces of coffee or tea/day?	Ounces soda or juice/day	Ounces other liquid/day
Eat Breakfast	Eat Lunch	Eat Dinner	Eat Snacks
Emotional Eating	Chocolate	Overeating	Food Cravings
Soda	Cookies	White Bread	Nutrasweet
Splenda	Cake or pie	Whole grain bread	Fried Foods
Sugar	Baked Goods	Fruit: Fresh or Dried
High Fructose Corn Syrup	Brown Rice	Fruit Juice	Processed Foods
Candy	Pizza	White Rice	Buffet Meals
Evening snacking	Eating at Night	Cereal	doughnuts /muffins
Slow Metabolism	Excessive Hunger	Aspartame	Alcohol
Fast Food	Comfort Foods	French Fries	Vegetables
Pasta	Automobile Meals		Corn: Chips, tortilla, etc

Medical History	Anemia	Psychiatric Disorder	Skin Problems
Chronic Obesity	Heart Disease	Cancer	Chronic Fatigue Syndrome
Diabetes Type 1	Hepatitis	Bloood Disorders	Malnutrition
Diabetes type 2	PregnancyWeight Gain	Anorexia or Bulimia	Stress
Hypoglycemia	Neurological Disorders	Depression	High Blood Pressure
Sinus Problems	Anxiety	Menstrual Problems	High Triglycerides
Kidney Disease	Thyroid Problems	Pain, Where?	Other Serious Condition
Gas and Bloating	Headaches	Sinus Problems	Allergies
Fatigue	Skin Problems	Frequent Colds
Pain + Inflammation	Poor Immunity	Chronic Illness	Breathing
Food Addiction	Alcohol/Drug Problem	Stop Smoking	Wrinkles
Other	Details		Feeling Overwhelmed

I'm interested in discussing these in my Plan:	Weight Coaching?	Detoxification	Injection Therapy
HCG	Help with Diet	Emotional Eating	Supplementation
Exercise	Group Therapy	Homeopathy	Health Information
Pain Management	Relapse	Body Shaping	Weight Loss IV Therapy
Cellulite Treatment	Heal Metabolism	Accountability	Physician Support
Dealing with Stress	Negative Thoughts	Get more active	Get out of my rut.
Make Healthy Choices	Wellness Priorities	Family	Staying on Track
Abdominal Fat Treatment	Social Pressure	Healthy Routine	Cooking + Recipies
Eating Healthier	Portion Control	Put me in charge.	Belly Fat Injections
Better Food Choices	Improve Sleep	Hormone Therapy	Heart Risk Reduction
Food Shopping Help	Skin Tightening	Offer Support	Remind me of my goals
Difficult Situations	Other	Family Support	Sugar etc. Addiction

I agree with Terms of Patient Intake Agreement

Patient Intake Agreement:

I agree that I have completed this questionnaire truthfully and accurately. Dr. Kiefer will be held harmless for patient's misinformation or ommission. . I will notify Dr. Kiefer or his staff of any changes (Name, Address, pregnancy status, etc..

SlenderShot's limited scope of diagnostic, case history, review of systems, physical exam, and treatment plannning do not represent a complete medical record.

I agree with Terms of Privacy Policies

View Printable Statement of Privacy Practices.

Your Privacy

I acknowledge that I have received a copy of the Statement of Privacy Practices from Gary Kiefer, ND. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility. My records will be kept confidential and will only be shared with the staff of Dr. Gary Kiefer, ND. My written consent is required for any sharing of information. Dr. Kiefer reserves the right to change the privacy practices that are describes in the Statement of Privacy Practices. If privacy practices change, a copy of the revised Statement of Privacy Practices will be offered at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me.

Additional Disclosure Authority: In addition to the allowable disclosure described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected healthcare information to the persons indicated: People , Relationship

We use and disclose the information we collect from you only as allowed by the Health Insurance Probability and Accountability Act and the state of Washington. This personal health information will never be otherwise given to anyone, even family members, without your written consent. You, of course, may give written authorization for us to disclose your information to anyone you choose, for any purpose.

Our offices and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality of your records is always protected. Our privacy policy and practices apply to all former, current, and future cliients, so you can be confident that your protected health information will never be improperly disclosed or released.

We will only request personal information needed to provide our standard of quality healthcare, implement payment activities, conduct normal healthcare practice operations, and comply with the law. This may include your name, address, telephone number(s), social security #, employment data, medical history, health records, etc.. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law.

As stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and governmental official under certain circumstances. We will not use your information for marketing purposes without your written consent.
We may use and/or disclose your health information to communicate reminders about your appointments including voicemail/answering machine messages, postcards, newsletters and special events.

You have the right to request copies of your healthcare information; to request copies in various formats; and to request a list of instances in which we, or our business associates, have disclosed your protected information for used other than stated above. All such requests must be in writing. We may charge you for copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services.

We thank you for being a patient at our office. Please let us know if you have any questions concerning your privacy rights and the protection of your personal health information.

I agree with Terms of Financial Policies

Insurance:	SlenderShot Weight Loss Program is structured to focus on weight control only, which is not typically covered by health insurance. Legitamate medical treatment (besides weight loss) will be scheduled on a seperate date in order to bill insurance. Note: Some Flex Spending Accounts do cover our services so check with your plan.
Appointments:	We require a 24-hour notice of appointment cancellation by phone or email. We do require payment to hold appointments. Please be on time for your appointment, as we do not refund appointment fees.
Payments:	We appreciate you staying current on your payments For returned checks we do charge a bank fee of $25. Post dated checks will not be accepted.
Legal	I agree to hold Dr. Kiefer harmless as a result of any legal controversies I agree to to use arbitration instead of the courts.

I agree with All Terms of Clinical Policies

Clinical Policies

Treatment Plan: I (as a patient) agree to	Participate in the developtment of my Treatment Plan Follow the plan to the best of my ability If the plan fails to provide desired results we will revise it Follow the revised plan. I understand that the Program is 90 days in duration
Compliance with Treatment: I (as a patient) agree to	Keep my therapy appointments Fully participate in treatment. Follow up consults Maintaining my diet Taking medication as directed Keep medications safe from children Keep records as directed Notify Dr. Kiefer of any changes in my medical condition immediately. I understand that I am free to discontinue participation in this treatment program at any time.
Anticipated Benefits and Claims:	Dr. Kiefer's SlenderShot Individualized Treatment Plans are designed to help patients understand many complex biological, emotional, hormonal, social, and psychological mechanisms. SlenderShot anticipates that with Treatment Plan compliance, patients will be in a better position to support metabolism wellness and control their weight. I agree that Dr. Kiefer has made no claims of how many pounds you will lose, that HCG is effective to reduce appitite, or is even effective in weight loss. I understand that the use of HCG in weight loss is not considered effective by the FDA, and that in treating weight loss with HCG is considered an "off label use" of HCG. I understand that the FDA requires that patients be informed that HCG has not been demonstrated to be effective adjunctive therapy in the treatment of obesity. There is no substantial evidence that it increases weight loss beyond that resulting from caloric restriction, that it causes a more attractive or "normal" distribution of fat, or that it decreases the hunger and discomfort associated with calorie- restricted diets. The FDA has not approved hCG for weight loss. Results vary. Most patients struggle in some way during the transitional process. Dr. Kiefer and the SlenderShot Staff are here to struggle with you. Hopefully the entire process will help mess up your binge eating, etc, and get back on track permenantly.
Risks and Complications	Possible side-effects are possible with any supplement, or medication, including HCG. These side-effects may result an allergic reaction or from normal detoxification. I agree to follow Dr. Kiefer's instructions when giving your own injections. When an injection is administered incorrectly, there is always a risk of infection at the injection site. SlenderShot Physicians will teach proper injection technique to prevent infection. It is important for the patient to follow injection directions carefully. If there is any question that the patient is unable to inject, we recommend oral, or sublingual forms of medication. Patients using prescribed or OTC medications need to inform Dr. Kiefer of any unusual symptoms or changes immediately. Even though weight loss is considered a healthy practice, medications may work differently when you start losing weight. If you are in a medical emergency, call 911, then later notify Dr. Kiefer.
Pregnancy and Breastfeeding (female client)	I agree to notify my doctor if I suspect pregnancy. Dr. Kiefer does recommend using SlenderShot medications including HCG when a woman is pregnant or breastfeeding.
Consent to Treatment	I agree to constent to Dr. Kiefer's treatment for medically supervised weight loss. I agree that Dr. Kiefer has explained that standard medical treatment for obesity is typically uses exercise, dietitian services, t, medications, and surgery. Often plastic surgury is utilized for wrinkles after weight loss. I understand that the SlenderShot Program, and Dr. Kiefer is not diagnosing or treating any diseases, rather he is developing healthy lifestyle choices for my long term wellness that will help me control my weight.

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