Services available to Nevada patients only. Medications are not shipped directly.
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Weight Management Questionnaire Page
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Name
This field is for validation purposes and should be left unchanged.
Are you currently living in Nevada?
(Required)
Yes
No
We currently only service patients who reside in Nevada. At this time, we are not able to mail prescriptions or ship medications out of state. If you are not in Nevada, we will not be able to provide services unless you are able to pick up your prescription in person at a Nevada partner pharmacy.
(Required)
Yes I can pick up
No I cannot pick up
Name
(Required)
First
Last
Date of birth
(Required)
MM slash DD slash YYYY
Phone
(Required)
By providing your mobile number, you consent to receive appointment-related and product-related text messages from Pure Fusion IV Lounge and its medical partners. Your information will remain confidential and is never shared without authorization. Msg & data rates may apply. Reply STOP to opt out. See Terms & Privacy Policy.
What is your sex?
(Required)
Male
Female
Do you plan on getting pregnant in the next 6 months?
(Required)
Yes
No
Height
(Required)
Weight
(Required)
What is your goal weight?
(Required)
Do you have any allergies (food, medication, etc)
(Required)
Yes
No
List your allergies
(Required)
Do any of these conditions apply to you? Check all that apply
(Required)
For your safety, some of these conditions may disqualify you from getting a prescription.
Diabetes Mellitus Type 1
Diabetes Mellitus Type 2
Had pancreatitis in the past
Thyroid cancer (or family history)
Diagnosed with multiple endocrine neoplasia type II
Diabetic retinopathy
History of renal disease or kidney dysfunction
History of gallbladder disease
Hypoglycemia
Diagnosed with fatty liver or non-alcoholic fatty liver disease
Hypertension (high blood pressure)
Diagnosed with obstructive sleep apnea
Cardiovascular disease (heart disease)
Difficulties in controlling your blood sugar levels
None of the above
Do you take any medication?
(Required)
Yes
No
What medication and what dosage?
(Required)
For example, Lisinopril 10mg 1 per day
Which best describes your current efforts toward weight management?
Actively managing my weight
Putting in some effort
Not actively managing my weight
Have you taken / used any of the following medication within 60 days?
(Required)
Semaglutide (Ozempic, Rybelsus, Wegovy)
Tirzepatide (Mounjaro, Zepbound)
None of the above
What is your most recent dosage?
(Required)
For example, 2.5mg weekly
Please choose an option below that you would like your provider to review.
(Required)
Increase dose (upload proof of prescription / dosage required)
Increase dose (provide pharmacy and provider information)
Keep the same dose or equivalent (upload proof of prescription / dosage required)
Keep the same dose or equivalent (provide pharmacy and provider information)
Decrease dose (upload proof of prescription / dosage required)
Decrease dose (provide pharmacy and provider information)
Restart or determine an appropriate dose (provider discretion)
Pharmacy
(Required)
The pharmacy that filled your most recent prescription
Phone
(Required)
Pharmacy phone number
Prescriber
(Required)
Provider who prescribed your most recent prescription
Phone
(Required)
Prescriber phone number
Proof of prescription and dosage (include date of prescription filled)
(Required)
It is important that we have proof of your current dosage in order to safely continue your treatment or determine the appropriate starting dose for your medication. If proof is not provided, your provider may start you at a lower dose for your safety.
Drop files here or
Select files
Max. file size: 64 MB.
Do you have a specific GLP-1 medication in mind?
(Required)
I would like a recommendation from a provider
Semaglutide
Tirzepatide
Do you have any other medical conditions, past surgeries, or additional information you would like your provider to know?
(Required)
Recent Lab Work
(Required)
Have you had lab work done in the past 6 months? (Required: Amylase, CMP, Lipase, Hemoglobin A1c, Insulin, TSH)
Yes - I will upload it
No - I understand lab work is required. I will purchase testing for $40 (must be added at checkout).
Upload lab work
(Required)
Max. file size: 64 MB.
LAB CONSENT
(Required)
I understand that the purpose of this consultation is to determine my eligibility for weight management medication, including but not limited to Semaglutide and Tirzepatide. I understand that in order to be eligible for these medications, I will need to provide valid results from the required lab tests:
Amylase
CMP
Lipase
Hemoglobin A1c
Insulin
TSH
If I am found to be eligible for weight management medication based on these results, I will be prescribed the appropriate medication. If I am not eligible, I will need to contact my primary care provider to work with them to obtain blood test results in accordance with the safety requirements of the medication.
Weight management treatment will not start until the provider has reviewed all required lab test results.
I will add the required labs at checkout ($40.00) as an additional service. I understand that failure to do so, may delay my consultation. I understand that all lab results must be reviewed by the provider before my appointment can be scheduled. By choosing to proceed, I confirm that I have read and understand the information and give my consent.
Name
(Required)
First
Last
Date
MM slash DD slash YYYY
The provider will wait for up to 15 minutes after the appointed time. If there was no appointment cancellation made at least 24 hours in advance, it will be considered a "No Call No Show," and I agree to pay a non-refundable fee of $50.
(Required)
Type full name
Date
(Required)
MM slash DD slash YYYY
NO CALL, NO SHOW POLICY CONSENT
(Required)
I understand and agree to the "No Call, No Show" policy
Notice of Privacy Practices (NPP) & SMS Opt-In Disclosure
(Required)
Notice of Privacy Practices (NPP) & SMS Opt-In Disclosure
Effective Date: 02/19/2026
At Pure Fusion IV Lounge, we are committed to protecting your privacy and maintaining the confidentiality of your Protected Health Information (PHI) in accordance with the Health Insurance Portability and Accountability Act and applicable Nevada state privacy laws.
Our Legal Duties
We are required by law to maintain the privacy of your protected health information, to provide you with this Notice describing our legal duties and privacy practices, and to notify you in the event of a breach of unsecured PHI.
We are also required to follow the terms of this Notice currently in effect and to provide you with a copy upon request.
Third-Party Sharing
We respect your privacy. No mobile information will be shared with third parties or affiliates for marketing or promotional purposes.
All the above categories exclude text-messaging originator opt-in data and consent; this information will not be shared with any third parties.
SMS Opt-In Disclosure
By providing your mobile number and opting in, you consent to receive SMS text messages from Pure Fusion IV Lounge regarding appointment reminders, health updates, and other information related to your care. Message frequency may vary. Standard message and data rates may apply.
Opt-Out: You may opt out of receiving SMS messages at any time by replying “STOP.” For assistance, reply “HELP” or contact us directly at the number below.
Privacy: Your consent, opt-in data, and mobile information will never be shared with third parties or affiliates for marketing or promotional purposes.
Your Rights Under HIPAA
When it comes to your health information, you have certain rights. This section explains those rights and our responsibilities.
You have the right to:
Access your medical records (paper or electronic).
Request amendments if you believe your records are inaccurate or incomplete.
Request confidential communications (e.g., specify contact method or address).
Request limitations on how your information is used or shared for treatment, payment, or operations.
Restrict disclosure to your health insurer when you pay out-of-pocket in full.
Receive an accounting of disclosures of your PHI.
Request a paper copy of this Notice at any time, even if you agreed to electronic delivery.
Choose someone to act for you if you have a legal guardian or medical power of attorney. We will verify that person’s authority before taking action.
File a complaint if you believe your rights have been violated.
You may exercise these rights by submitting a written request to our Privacy Officer at the contact information listed below.
Your Choices
You have choices about how we use and share certain information.
In these cases, you have both the right and choice to tell us to:
Share information with family members, close friends, or others involved in your care or payment.
Share information for disaster-relief purposes.
If you have a clear preference for how we share your information, please tell us. We will follow your instructions whenever possible.
We will never use or share your information without your written authorization for:
Marketing purposes
The sale of your information
Most uses of psychotherapy notes
How We Use and Disclose Your Information
We may use and disclose your PHI for the following purposes:
Treatment: Sharing information with other healthcare providers to ensure you receive appropriate care.
Payment: Processing payment for services and billing.
Healthcare Operations: Quality assessment, staff training, licensing, and business planning.
We may also use or share your health information in other situations as permitted or required by law, including:
Public Health and Safety: Preventing disease, reporting adverse reactions or suspected abuse, and helping with recalls.
Research: Using or sharing data for approved health research.
Compliance with the Law: Responding to lawful requests by U.S. Department of Health and Human Services Office for Civil Rights or other agencies.
Organ and Tissue Donation: Responding to organ-donation requests.
Coroners and Funeral Directors: Assisting with identification or other lawful duties.
Workers’ Compensation, Law Enforcement, and Government Requests: Addressing claims, investigations, and other lawful activities.
Lawsuits and Legal Actions: Responding to court orders, subpoenas, or administrative proceedings.
To the extent we maintain any substance-use-disorder records, we comply with federal confidentiality rules under 42 CFR Part 2. We will not share those records for legal or investigative purposes without your written consent or a valid court order and subpoena.
Other disclosures will only be made with your written authorization unless otherwise permitted or required by law.
Breach Notification
If a breach of unsecured PHI occurs, we will notify you as required by HIPAA. Notifications will include:
A brief description of what happened
The types of PHI involved
Steps you should take to protect yourself
What we are doing to investigate and mitigate the breach
Safeguards We Use
We maintain administrative, physical, and technical safeguards to protect your health information:
Administrative: Staff training and access controls
Physical: Secure facilities and locked storage
Technical: Encryption, secure email, and password-protected systems
We also comply with the Minimum Necessary Standard, using only the least amount of PHI needed to perform a task.
Our Responsibilities
We are required by law to maintain the privacy and security of your protected health information.
We will notify you promptly if a breach occurs that may have compromised your information.
We must follow the duties and privacy practices described in this Notice and provide you a copy upon request.
We will not use or share your information other than as described here unless you give us written permission. You may revoke permission in writing at any time.
We will not retaliate against you for filing a complaint.
For more information or to file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights, visit https://www.hhs.gov/hipaa/filing-a-complaint/index.html or call 1-877-696-6775.
State Law: Nevada Consumer Health Data Privacy Act
In addition to the federal HIPAA privacy protections described above, Nevada has enacted the Nevada Consumer Health Data Privacy Law, which provides additional safeguards for health-related information collected from Nevada residents.
Under this law, Nevada residents may have additional rights concerning the collection, use, and sharing of consumer health data, including the ability to provide or withdraw consent for specific uses or disclosures. Where applicable, Pure Fusion IV Lounge will comply with these state-law requirements. Information already protected under HIPAA may be exempt from certain provisions of this law.
Nevada law may also provide additional privacy protections for certain types of health information, including mental-health, substance-use, and HIV-related records. We will comply with those state-specific requirements where applicable.
Changes to This Notice
We may change the terms of this Notice, and the changes will apply to all information we have about you. The revised Notice will be available upon request, in our office, and on our website.
Contact Information & Privacy Officer
If you have questions, requests, or concerns about this Notice, your privacy rights, or SMS communications, please contact our Privacy Officer:
Privacy Officer
Pure Fusion IV Lounge
Phone: (725) 254-2721
Address: 8440 W. Lake Mead Blvd, Las Vegas, NV 89128
I have read and understand the Privacy Practices and consent to these terms.
Terms of Services
(Required)
Terms of Service
Effective Date: 02/19/2026
Welcome to Pure Fusion IV Lounge (“Pure Fusion,” “we,” “our,” or “us”). These Terms of Service (“Terms”) govern your access to and use of our telehealth services, medical consultations, IV therapy, weight-management programs, and related treatments (“Services”).
By accessing or using our Services— in-person, or through telehealth—you acknowledge that you have read, understand, and agree to these terms.
1. Acceptance of Terms
By scheduling an appointment, completing an intake form, or using any of our telehealth platforms, you agree to be bound by these Terms and applicable Nevada and federal laws. If you do not agree, please do not use our Services.
2. Eligibility
You must be at least 18 years old to use our Services. By using our Services, you confirm that you are legally able to enter into this agreement and provide accurate and complete health information.
3. Scope of Services
Pure Fusion IV Lounge provides medical and wellness services including, but not limited to:
• Telehealth consultations for weight management
• Prescription and medical supervision of weight-management medications
• IV therapy and nutritional infusions
• Wellness and lifestyle support
All medical services are provided by licensed healthcare professionals in accordance with the standard of care and state telehealth laws.
4. Provider Licensing and Telehealth Requirements
a. Licensed Providers: All healthcare providers delivering telehealth or medical services through Pure Fusion IV Lounge are licensed in the State of Nevada, in compliance with NRS § 629.515 and applicable Nevada Board of Medical Examiners regulations.
b. Establishment of a Patient–Provider Relationship: A valid provider–patient relationship is established when a licensed provider conducts a telehealth evaluation and determines that treatment is appropriate.
c. Telehealth Consent: By using our telehealth services, you consent to receive healthcare via audio, video, or electronic communication. You understand that telehealth may have limitations compared to in-person visits.
5. Informed Consent for Telehealth
You understand and agree that:
• Telehealth involves the electronic transmission of your medical information.
• Technical issues (e.g., poor connection or interruptions) may occur.
• You can withdraw your consent to telehealth at any time.
• Not all conditions or treatments are suitable for telehealth evaluation.
6. Prescription Policy
Prescriptions, including weight-loss medications such as GLP-1s or adjunct therapies, will only be issued when medically appropriate following evaluation by a licensed provider.
All prescribing complies with Nevada telehealth regulations and federal law (including DEA and FDA guidelines). Controlled substances will not be prescribed without a valid in-person or telehealth medical evaluation as permitted by law.
7. Privacy and Confidentiality
Pure Fusion IV Lounge complies with the Health Insurance Portability and Accountability Act (HIPAA), Nevada Revised Statutes Chapter 629, and all applicable privacy and data security laws.
Our Privacy Policy and Notice of Privacy Practices describe how we collect, use, disclose, and protect your health information. You acknowledge receipt of these notices by continuing to use our Services.
8. Communication and Technology
You agree to:
• Provide accurate contact and health information.
• Use only secure, approved platforms for telehealth appointments.
• Maintain privacy on your end during telehealth sessions.
You understand that communications (email, text, or phone) may be used for appointment scheduling, treatment updates, or follow-up reminders. While we use HIPAA-compliant systems, you acknowledge that standard messaging may carry limited security.
9. Payment and Billing
All payments are due at the time of service unless otherwise arranged.
Pure Fusion IV Lounge only accepts self-pay. You are responsible for all costs associated with your care. Prices are subject to change without notice.
10. Limitations and Risks
You understand that telehealth and wellness services are not a substitute for emergency or in-person medical care. If you experience an emergency, call 911 or go to your nearest emergency department.
Pure Fusion IV Lounge does not guarantee specific results or outcomes from any treatment or program.
11. Termination of Services
We reserve the right to suspend or terminate your access to our Services for any reason, including violation of these Terms, inappropriate conduct, or fraudulent activity.
12. Dispute Resolution and Governing Law
These Terms shall be governed by and construed in accordance with the laws of the State of Nevada. Any disputes will be resolved in the state or federal courts located in Clark County, Nevada.
13. Changes to Terms
Pure Fusion IV Lounge reserves the right to modify these Terms at any time. Updated versions will be posted on our website and become effective immediately upon posting.
I have read and understand the Terms of Services and consent to treatment under these terms.
Review
(Required)
By clicking submit and making a purchase, I accept a self-pay arrangement. I agree to the Terms of Service and Privacy Policy of Pure Fusion IV Lounge. If prescribed, I authorize my payment method to be charged. I confirm that the information I have provided, and will provide, is true and complete to the best of my knowledge. I understand that sharing accurate and complete health information is essential to my care, and I agree not to hold the prescribing provider or affiliated medical practice responsible for any errors or omissions in the information I have supplied.
Patient Name
(Required)
First
Last
Today's Date
(Required)
MM slash DD slash YYYY
Date
MM slash DD slash YYYY
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