Medication Management Appointment Request Form

Medication Management Appointment Request Form

Patient Intake Questionnaire
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Cell Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Responsible Party (Required for minors)

First NameLast Name
Responsible Party's Cell Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Are you a currently being seen by a provider at Vendetti Wellness Group?
Most of our Medication Management visits are conducted virtually. However, certain conditions are most effectively managed with in-person care, which we may not always be able to provide in a virtual setting. Please select the reason you are seeking Medication Management services: (Check all that may apply)
If you selected "Other" from above, please specify:
If you are experiencing thoughts of self-harm or are in immediate crisis, please call 911 or reach out to the Suicide and Crisis Hotline at 988 for support.
Does the patient reside in Massachusetts?
If you reside outside of Massachusetts, all Medication Management visits must be conducted in person.
Is the patient currently residing in a therapeutic setting, such as a group home, residential program, inpatient program, or attending a partial program or day treatment?
If "Other" is selected above, please explain below:
Primary Care Physician (PCP):

First NameLast Name
PCP's Phone #:
Please enter a valid phone number.Format: (000) 000-0000.
Medical History
List all current prescription medications and how often you take them
Current medical problems
Are you currently pregnant, planning to become pregnant, or have you had a baby in the past year?
Psychiatric History:
Psychiatric Hospitalization
If yes, please list hospital names and dates:
If yes, please describe when, by whom, and nature of treatment:
If you selected "Yes" to a past psychiatric hospitalization within the past three (3) months, please have your discharge summary faxed to 774-250-2693 and/or emailed to intake@vendettiwelllnessgroup.com. Failure to provide this information may result in appointment scheduling delays.
Past Psychiatric Medications

If you have ever taken any of the following medications, please indicate the dates and daily dosage.

Rows	Have you ever taken it?	Dates	Dosage	Side Effects?
Prozac (fluoxetine)
Zoloft (sertraline)
Luvox (fluvoxamine)
Paxil (paroxetine)
Celexa (citalopram)
Lexapro (escitalopram)
Effexor (venlafaxine)
Cymbalta (duloxetine)
Wellbutrin(bupropion)
Remeron (mirtazapine)
Serzone (nefazodone)
Anafranil (clomipramine)
Pamelor (nortrptyline)
Tofranil (imipramine)
Elavil (amitriptyline)
Tegretol (carbamazepine)
Lithium
Depakote (valproate)
Lamictal (lamotrigine)
Tegretol (carbamazepine)
Topamax (topiramate)
Seroquel (quetiapine)
Zyprexa (olanzepine)
Geodon (ziprasidone)
Abilify (aripiprazole)
Clozaril (clozapine)
Haldol (haloperidol)
Prolixin (fluphenazine)
Risperdal (risperidone)
Ambien (zolpidem)
Sonata (zaleplon)
Rozerem (ramelteon)
Restoril (temazepam)
Desyrel (trazodone)
Adderall (amphetamine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Strattera (atomoxetine)
Xanax (alprazolam)
Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Tranxene (clorazepate)
Buspar (buspirone)

Other medications?
How would you describe your relationship with alcohol?
Do you use drugs?
Please provide any additional information you'd like to share:
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I, the undersigned, hereby consent to participate in a telehealth/telephone screening review conducted by a registered nurse as part of my healthcare evaluation and treatment. I understand that telehealth/telephone communication involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. I understand that the information transmitted may include my medical history, diagnosis, treatment, and other related healthcare information. I understand that while efforts will be made to protect the privacy and security of my health information, there are inherent risks associated with electronic communication, including but not limited to breaches of confidentiality, unauthorized access, and technical failures. I understand that the registered nurse conducting the screening review will take appropriate measures to safeguard my health information but cannot guarantee absolute security. I understand that the registered nurse will bill my insurance provider for the telehealth/telephone screening review services provided to me. I authorize the release of any medical or other information necessary to process claims for these services. I understand that I may be responsible for any co-payments, deductibles, or other out-of-pocket expenses as determined by my insurance plan. I understand that telehealth/telephone communication may not be appropriate for all medical conditions and that there may be limitations to the evaluation and treatment that can be provided through this modality. If, during the course of the screening review, the registered nurse determines that an in-person evaluation is necessary, I understand that I may be referred to an appropriate healthcare provider for further assessment and treatment. I have had the opportunity to ask questions about the telehealth/telephone screening review process, and all of my questions have been answered to my satisfaction. I hereby consent to participate in the telehealth/telephone screening review and authorize the registered nurse to provide necessary healthcare services through this modality. I understand that I have the right to withdraw this consent at any time. Assessments/Diagnostic Evaluations: The fee for an evaluation is based on the number and type of tests included in the assessment battery. Vendetti Wellness Group does bill a variety of insurance companies for these assessments. In some cases, your insurance may pay all or only a portion of these tests. Copayments, Coinsurances, and deductibles may be applied based on your individual insurance policy. Payment is due at the time of services being rendered. Late cancellations and No-Show fees may apply for failure to notify your clinician of a cancellations 24 hours in advance, or for not showing to your schedule session. I understand that the information obtained in this evaluation is confidential and will not be released to any person or organization without my written permission. (This release is available in our office or may be completed with any individual whom you wish to give such access, and then provided to us.) The only exceptions to this policy are rare situations in which you are required by law to release information with or without my permission. These are: 1) if there is evidence of physical and/or sexual abuse of children or abuse to the elderly; 2) if you judge that I am in danger of harming myself or another individual; and 3) if my records are subpoenaed by the court. In the rare event of any of these situations, you would attempt to discuss your intentions with me before an action is taken, and you would limit disclosure of confidential information to the minimum necessary to ensure safety. Additional paperwork may be required at the time of an appointment scheduling.
Signature
Guardian Signature (if under age 18)
Should be Empty:

Medication Management Appointment Request Form

If you are experiencing thoughts of self-harm or are in immediate crisis, please call 911 or reach out to the Suicide and Crisis Hotline at 988 for support.

Medical History

Psychiatric History:

Past Psychiatric Medications