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Start Your Wellness Journey

Welcome to Hope

Thank you for choosing Hope Health & Wellness. Please complete the sections that apply to you. Your information is used to prepare for safe, personalized, physician-led care.

1. Patient Registration

Legal name(Required)

Preferred name(Required)

Date of birth(Required)

Pronouns

Street address(Required)

City / State / ZIP(Required)

Cell phone(Required)

Email(Required)

Preferred pharmacy + phone(Required)

Primary care physician + phone(Required)

How did you hear about Hope?(Required)

Emergency contact name(Required)

Emergency contact phone(Required)

Preferred contact(Required)

Phone

Text

Voicemail

Location of care(Required)

2. Tell Us About You

What would you most like help with?(Required)

Weight management

Hormone health

Energy / recovery

IV or vitamin therapy

Peptide / cellular wellness

Healthy longevity

Your goals and concerns(Required)

Medical conditions(Required)

Diabetes / prediabetes

High blood pressure

High cholesterol / triglycerides

Heart disease / heart failure

Heart attack / stroke

Blood clot / clotting disorder

Kidney disease

Liver disease

Gallbladder disease

Pancreatitis

Thyroid disorder

Cancer (current or history)

Seizure disorder

Autoimmune condition

HIV / hepatitis

Bleeding disorder

G6PD deficiency

Gastroparesis / severe GI disease

Eating disorder

Mental health condition

Sleep apnea

Bariatric surgery

Other

Surgeries / hospitalizations(Required)

Allergies and reactions(Required)

Medications, vitamins, and supplements(Required)

Name

Dose

How often

Reason

Prior wellness treatments and reactions(Required)

Pregnancy / reproductive safety(Required)

Not applicable

Pregnant

Trying to become pregnant

Breastfeeding

Using contraception

Typical hours of sleep(Required)

Exercise type/frequency(Required)

Alcohol drinks/week(Required)

Tobacco/vape use(Required)

3. HIPAA Acknowledgment

I acknowledge that I received or was offered Hope Health & Wellness's Notice of Privacy Practices and may request a current paper or electronic copy at any time.

3. HIPAA Acknowledgment(Required)

I received the Notice

I was offered the Notice but declined a copy

4. Financial & Appointment Agreement

Hope Health & Wellness is private pay and does not bill insurance. Payment is due at the time of service. A valid payment card is securely maintained to reserve appointments. Appointments canceled with less than 48 hours' notice, or missed without notice, may be charged $100. Fees may be waived for genuine emergencies or exceptional circumstances at the practice's discretion.

Untitled(Required)

I agree to the private-pay, payment, 48-hour cancellation, $100 late-cancellation/no-show, and secure card-on-file terms.

Card details must be collected through a secure payment processor - never through this plain form.

5. Communication Consent

Untitled(Required)

Phone call

Voicemail

Text / SMS

Patient portal

I understand that ordinary email and text can have privacy risks and that I may withdraw permission in writing.

7. Electronic Signature

Type full legal name(Required)

Date(Required)

Untitled(Required)

I certify that my information is accurate and that typing my name is intended as my electronic signature for this draft form.

Begin Your Welcome Packet

Your Weight-Loss Journey

Physician-led medical weight management focused on sustainable fat loss, preservation of lean mass, metabolic health, and long-term quality of life.

1. The Hope Method

1. Consult

History, goals, medications

2. Evaluate

Labs and body composition

3. Personalize

Nutrition, activity, treatment

4. Begin

Training and first month

5. Follow Up

Monthly physician review

6. Maintain

Long-term strategy

2. Treatment Interest

Untitled(Required)

Lifestyle-focused program

Brand-name semaglutide

Brand-name tirzepatide

Patient-specific compounded preparation if lawful and appropriate

Compounded drugs are not FDA-approved, and availability may change. Retatrutide is investigational and is not offered as a routine prescription treatment by Hope.

3. Safety Screening

Untitled(Required)

MTC or MEN 2 history

Pregnancy / trying / breastfeeding

Pancreatitis

Gallbladder disease

Kidney disease

Severe GI disease / gastroparesis

Eating disorder

Planned surgery / anesthesia

Details(Required)

4. Current Prescription

Medication(Required)

Brand or pharmacy(Required)

Concentration(Required)

Prescribed dose(Required)

Injection day(Required)

Start date(Required)

5. Monthly Follow-Up Agreement

I agree to attend follow-up, complete requested testing, report side effects, use medication only as prescribed, and request refills with enough time for clinical review and pharmacy processing.

Untitled(Required)

I agree.

6. Informed Consent

I understand the potential benefits, common side effects, serious risks, alternatives, no-treatment option, pregnancy precautions, thyroid C-cell tumor warning, risks of dehydration and kidney injury, pancreatitis, gallbladder disease, severe gastrointestinal effects, hypoglycemia with certain diabetes medicines, allergic reaction, anesthesia considerations, and the differences between FDA-approved and compounded products.

Untitled(Required)

My history is accurate.

I will follow dosing instructions.

I understand results are not guaranteed.

My questions have been answered.

7. Electronic Signature

Type full legal name(Required)

Date(Required)

Untitled(Required)

Typing my name is intended as my electronic signature for this draft form.

Book Your Weight-Loss Consultation

Peptide Therapy & Cellular Wellness Patient Education

Hope Health & Wellness

Packet 3: Peptide Therapy & Cellular Wellness Patient Education + Informed Consent Packet Yasaman Omidvar, M.D. Double Board Certified in Family Medicine & Obesity Medicine

Welcome

Thank you for choosing Hope Health & Wellness. Peptide therapy is a personalized physician-guided approach focused on education, safety, individualized recommendations, and ongoing physician partnership.

What Are Peptides?

Peptides are short chains of amino acids that act as signaling molecules in the body. They may support pathways related to cellular wellness, recovery, metabolic health, and healthy aging.

Examples of Peptides Discussed

Recovery & Tissue Support: BPC-157, TB-500
Skin & Cellular Wellness: GHK-Cu
Metabolic Wellness: AOD-9604
Cellular Energy & Antioxidant Support: NAD+, Glutathione
Growth Pathway Discussion: CJC-1295, Ipamorelin

Safety, Risks & Considerations

Potential considerations may include injection-site reactions, headache, nausea, fatigue, water retention, changes in blood pressure or glucose, and allergic reactions. A complete medical evaluation is required before treatment decisions.

The Peptide Therapy Process

1. Consultation
2. Comprehensive Evaluation
3. Personalized Plan
4. Education & Implementation
5. Follow-Up & Optimization

Informed Consent

I acknowledge receiving education regarding peptide therapy, including potential benefits, risks, limitations, and alternatives.

Patient Signature(Required)

Your Name
Your Name
Your Name

Cancellation & Appointment Policy

Appointments cancelled with less than 48 hours notice or missed appointments may result in a $100 cancellation fee. Credit card authorization may be maintained according to practice policy.

Disclaimers & Limitations

Peptide therapy does not replace healthy nutrition, exercise, sleep, stress management, or appropriate medical care. Results vary by individual and recommendations are physician-guided.

Review & Complete Packet

IV Hydration & Vitamin Therapy

Hope Health & Wellness

Packet 5: IV Hydration & Vitamin Therapy

Welcome to Iv Hydration & Vitamin Therapy

At Hope Health & Wellness, IV hydration and vitamin therapy are physician-guided wellness services designed around your individual health goals.

What is Iv Hydration Therapy?

Intravenous therapy delivers fluids, vitamins, minerals, and nutrients directly into the bloodstream. Each treatment is personalized based on patient goals and clinical considerations.

Vitamin Therapy Education

B12 & B-Complex: Nutrient support and wellness optimization.
Vitamin D: Support when clinically appropriate.
Glutathione: Antioxidant and cellular wellness support.
NAD+: Cellular energy and healthy aging discussions.

IV Therapy Options at Hope

Hydration IV, Energy & Wellness IV, Recovery IV, Immune Support IV, and customized nutrient combinations.

GLP-1 Wellness Support

Hydration and nutritional support strategies may complement physician-guided weight management programs.

The Hope IV Therapy Process

Consultation → Personalized treatment selection → Administration → Monitoring → Follow-up guidance.

Safety, Risks & Considerations

Potential risks include IV site irritation, bruising, infection risk, allergic reactions, and nutrient-specific considerations.

Informed Consent & Policies

Benefits, risks, alternatives, limitations, financial policy, cancellation policy, and follow-up expectations are reviewed.

Frequently Asked Questions

IV therapy complements healthy nutrition, movement, sleep, and lifestyle habits.

A Note From Dr. Yassi

Thank you for trusting Hope Health & Wellness. Our mission is personalized, physician-led care supporting your wellness journey.

View Patient Packet Start Your IV Therapy Packet

Contact Us & Submit Your Documents

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Submit Your Information

Patient Forms

Start Your Wellness Journey

Welcome to Hope

Welcome to Hope

1. Patient Registration

2. Tell Us About You

3. HIPAA Acknowledgment

4. Financial & Appointment Agreement

5. Communication Consent

7. Electronic Signature

Your Weight-Loss Journey

Your Weight-Loss Journey

1. The Hope Method

1. Consult

2. Evaluate

3. Personalize

4. Begin

5. Follow Up

6. Maintain

2. Treatment Interest

3. Safety Screening

4. Current Prescription

5. Monthly Follow-Up Agreement

6. Informed Consent

7. Electronic Signature

Peptide Therapy & Cellular Wellness Patient Education

Hope Health & Wellness

Welcome

What Are Peptides?

Examples of Peptides Discussed

Safety, Risks & Considerations

The Peptide Therapy Process

Informed Consent

Cancellation & Appointment Policy

Disclaimers & Limitations

IV Hydration & Vitamin Therapy

Hope Health & Wellness

Packet 5: IV Hydration & Vitamin Therapy

Welcome to Iv Hydration & Vitamin Therapy

What is Iv Hydration Therapy?

Vitamin Therapy Education

IV Therapy Options at Hope

GLP-1 Wellness Support

The Hope IV Therapy Process

Safety, Risks & Considerations

Informed Consent & Policies

Frequently Asked Questions

A Note From Dr. Yassi

Contact Us & Submit Your Documents

Contact Form

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