WELCOME TO OUR PRACTICE Please answer the following questions so we can better assist your healthcare needs.

PATIENT INFORMATION Date____________ Soc. Sec. # _________________________________ Birth Date Name (Last Name)

(First Name)

(Initial)

Address___________________________________________ City___________________________ Please Circle Sex:

M/F

Home Phone (____)

State _________ Status:

(Maiden Name)

Zip Code

Minor / Single / Married / Divorced / Widowed / Separated

Employer _____________________________________ Occupation E-Mail Address Emergency contact: _______________________________ Phone (____) Name of friend/family member so they may receive $10.00 off: Please list your present health concerns, problems, or symptoms:

How have you attempted to lose weight in the past? (exercise, diet, medications, behavioral therapy, etc) Exercise NutriSystem

Diet

Medications Adkins Diet

Behavioral therapy

17 Day Diet

Jenny Crai

South Beach Diet

Wt Watchers

Mediterranean Diet

Other: How many days per week do you get moderate exercise? (35-40 minutes of walking, etc.) What type(s) of exercise are you currently doing?

What are your current eating habits (low/high calorie, low/high fat, low/high carbohydrate, mostly fast food, fried foods, vegetarian, vegan etc.)?

MEDICAL HISTORY When was your last physical exam? Physician’s Name: _____________________________________________

1. Are you currently under medical treatment? Please describe: 2. Have you ever had any serious illness or operations? Please describe:

Phone (_____)

YES / NO

YES / NO

3. Are you currently taking any medications? Please list all medications (prescribed or over-the-counter):

YES / NO

4. Are you currently taking any supplements, vitamins, etc.? Please list all:

YES/NO

5. 6. 7. 8.

YES / NO YES / NO YES / NO YES / NO

Do you smoke? Do you use alcohol? Do you use cocaine or other drugs? Have you had any allergic reactions to the following? Local Anesthetics (e.g. Novocain) Penicillin, Sulfa, or other antibiotics?

9. Do you have a history of eating disorders (anorexia, bulimia, binge eating, etc.)? Explain:

10. Do you have any family members with a history of weight problems, physical illnesses/conditions, or psychiatric illnesses? If so, please list what family members and what conditions:

WOMEN ONLY – Do you have regular periods? Have you ever been pregnant? Number of pregnancies _______________ Please circle one:

YES / NO YES / NO

Have you ever had a tubal ligation, (tying of tubes) ablation, or hysterectomy? YES / NO Do you currently have an IUD or take birth control pills? YES / NO

Review of Systems PLEASE INDIVIDUALLY CHECK EACH CONDITION YOU CURRENTLY HAVE OR HAVE HAD IN THE PAST Name: _______________________________________________ Constitutional High Blood Pressure Fatigue Change in appetite Headaches/migraines

Date of Birth: _______________________

Respiratory Cough Shortness of breath Wheezing Emphysema/COPD Asthma Gastrointestinal Constipation Nausea/vomiting Abdominal pain Heartburn/acid reflux Irritable bowel syndrome Hepatitis Type _________

Eyes Glaucoma Eye glasses/contacts Blurred/double vision

Neurological Headaches Numbness/tingling Tremors Seizures/Epilepsy Stroke

Musculoskeletal Joint pain/stiffness Muscle pain/weakness Back pain/problems Arthritis Carpal tunnel syndrome Fibromyalgia Gout

Hematologic/lymphatic Bleeding/bruising tendency Blood clots Cancer Anemia (low blood count) Blood Disease

Skin Rashes Lesions Ulcers Jaundice

Cardiovascular Chest pain/angina Palpitations Murmur Swelling of feet/ankles Congenital Heart lesion Heart Disease Pacemaker High Cholesterol

Psychological Bipolar Depression Anxiety Psychiatric care Stress Please list any psychiatric history including diagnoses & treatments: ________________ ____________________________________ ____________________________________

Endocrine Thyroid issues Diabetes

Other Chemical dependency Chemotherapy Chronic fatigue syndrome Rheumatic Fever Scarlet Fever Tuberculosis HIV/AIDS

Ears/nose/mouth/throat Hearing loss Nosebleeds Trouble swallowing Bleeding gums Sore throat Problems with thyroid Sinus Trouble

Genitourinary Problems with urination Blood in urine Kidney stones Prostate enlargement Polycystic Ovarian Disease (PCOS/PCOD)

Please list & describe any other medical conditions not listed above: _____________ ____________________________________ ____________________________________

Past Surgical History PLEASE INDIVIDUALLY CHECK EACH SURGICAL PROCEDURE YOU HAVE HAD IN THE PAST Name: ______________________________________________ Cardiac Surgery Pacemaker Bypass Stents

Gastrointestinal Surgery Gallbladder Gastric bypass Lap-band Hernia repair

Gynecological Surgery Hysterectomy With ovaries removed W/out ovaries removed Tubal ligation Caesarean Section Ablation

Genitourinary Surgery Kidney Stents (kidney stones) Vasectomy Laser (for stones)

Date of Birth: ___________________________ Orthopedic Surgery Joint replacement Arthroscopic (Scope) Spinal fusion/discectomy/laminectomy

Please list any other surgical procedures you have had not listed above:

________________________________

______________________

Patient Signature

Date

RECORDS RELEASE- Release of records to you the patient. To: Gregory Weckenbrock, M.D. 157 Barnwood Drive Edgewood, KY 41017

I hereby authorize you to release to (Patient’s Name) Any information including the diagnosis and records of any treatment or examination rendered to me during the period from (Today’s Date) ___________________________ to end of program.

Signature

Witness

Full Address

PRESCRIPTION MEDICATION REVIEW For your safety and treatment in our program, please mark YES or NO for ANY and ALL medications you are CURRENTLY prescribed or have been prescribed in the PAST YEAR (past 12 months). MEDICATION Abstral (Fentanyl Transmucosal) Adderall (Dextroamphetamine) Adipex-P (Phentermine) Alprazolam (Xanax) Ambien (Zolpidem) Amphetamines Ativan (Lorazepam) Avinza (Morphine Sulfate) Bontril (Phendimetrazine) Butrans(Buprenorphine) Buprenex (Buprenorphine) Butalbital Butorphanol Carisoprodol (Soma) Clonazepam (Klonopin) Clorazepate (Tranzene) Codeine Concerta (Methylphenidate) Cyclobenzaprine (Flexeril) Darvocet Darvon Demerol (Meperidine) Dexedrine (Dextromethamphetamine) Diazepam (Valium) Didrex (Benzphetamine) Dilaudid (Hydromorphone) Dolophine (Methadone) Duragesic (Fentanyl Transderm) Duramorph Endocet (Oxycodone/Acetaminophen) Esgic/Esgic plus Fastin Fentanyl Fioricet/Fiorinal Flexeril (Cyclobenzaprine) Gabapentin (Neurontin) Halcion (Triazolam) Hydrocodone (Lortab/Lorcet/Vicodin) Hydromorphone Ionamin Kadian (Morphine) Ketorolac (Toradol) Klonopin (Clonazepam) Librium (Clordiazepoxide) Lorazepam (Ativan) Lorcet Lortab

YES

NO

MEDICATION Lunesta Marinol (Dronabinol) Meperidine (Demerol) Methadone Methocarbamol (Robaxin) Methylphenidate Midazolam (Versed) Morphine MS Contin/MS IR Naltrexone (Vivitrol/ReVia) Neurontin (Gabapentin) Norco (Hydrocodone/Acetaminophen) Norflex (Orphenadrine) Nucynta (Tapentadol) Numorphone Orphenadrine Oxycodone Oxycontin Oxymorphone Percocet (Oxycodone/Acetaminophen) Percodan (Oxycodone/Aspirin) Propoxyphene (Darvon) Rozerem Revia Robaxin (Methocarbamol) Roxicet Roxicodone Soma (Carisoprodol) Stadol Suboxone Subutex Talacen (Pentazocine/Acetaminophen) Talwin (Pentazocine) Temazepam Tenuate Toradol Tramadol Triazolam Tylenol w/codeine (Tylenol #3) Tylox Ultram (Tramadol) Ultracet (Tramadol/Acetaminophen) Valium (Diazepam) Vicodin (Hydrocodone) Vivitrol Xanax

YES

NO

Please list any additional medications you are CURRENTLY prescribed or have been prescribed in the PAST YEAR.

I, __________________________________, verify I have noted any medications I am CURERNTLY taking or have TAKEN in the past 12 months. Date__________________ Patient Signature____________________________ Witness_____________________________

ALL FEMALE PATIENTS SHOULD READ AND SIGN THIS PAGE PLEASE NOTE: The medical providers and staff of Figure Weight Loss recommend and strongly encourage the consistent use of contraception to avoid pregnancy during treatment with our medications for ALL females of childbearing age. This is due to the increased risk of teratogenicity (fetal harm/damage) with the use of our medications. By signing below, I am stating that I have read this document and understand the importance of using contraceptive methods while taking these medications. I understand if I should become pregnant, I should discontinue the use of these medications immediately and report my pregnancy to Figure Weight Loss and its health care providers.

Signature

________________________ Date

Printed Name

________________________ Date of Birth

Witness Signature

________________________ Date

I, ______________________, a patient of this office, hereby acknowledge that I have been given a list of possible side effects of the medications that I may be taking. LISTED BELOW ARE POSSIBLE SIDE EFFECTS FROM ALL MEDICATION PRESCRIBED FROM THIS OFFICE: Confusion / Amnesia Headaches Weakness Changes in Sex Drive Sleep Disturbance Tremors Dry Mouth Blurred Vision Depression Fatigue / Drowsiness Heart Pounding Fast Heart Rate High Blood Pressure Nausea Constipation Diarrhea Abdominal Cramping Allergic Reaction Reaction with General Anesthesia Death Primary Pulmonary Hypertension Heart Valve Disorder Psychiatric Illness Potential for Dependency May impair the ability to operate a motorized vehicle / heavy equipment

I HAVE BEEN INFORMED THAT I SHOULD NOT GET PREGNANT WHILE TAKING THIS MEDICATION AND THE USE OF PROPER BIRTH CONTROL IS A MUST WHILE ON THIS PROGRAM. I know to stop taking the medication and report to this office if any of the following occurs: Decreased Exercise Tolerance Unexplained Shortness of Breath Loss of Consciousness Chest Pain Leg Swelling Blurred Vision I understand that weight loss alone carries some risk, including Gall Bladder Disease. I acknowledge that I have listed all medications that I am currently taking, prescription or over the counter, on my Personal History Form, or notified the staff of this office, whether the same be on a regular basis or temporary basis. I understand that before I might begin taking other medications that I have not listed on my Personal History Form, that I will notify the attending physician or staff member of this office. I understand that it is my responsibility to maintain a physician / patient relationship with my primary doctor. It is also my responsibility to ensure that a complete physical examination has been performed, as well as having satisfactory laboratory tests performed that include CBC, fasting blood sugar, thyroid panel or TSH, lipid profile, serum potassium, liver function test, and renal function test. I agree to notify the attending physician(s) or a staff member of this office of any abnormalities regarding the above tests. If I should have any other questions about the medications prescribed to me at this office I will ask the attending physician(s) or staff member for the said answer. Subsequent to leaving the office, should I have any questions, I will notify the office staff of this office by phone or person. I hereby agree that I will take medications prescribed to me by the physician(s) of Figure Weight Loss as directed. Patient ________________________________________________

Date

Witness _______________________________________________

Date

IF YOU WOULD LIKE A COPY OF THE POSSIBLE SIDE EFFECTS PLEASE ASK THE RECEPTIONIST.

157 BARNWOOD DRIVE SUITE 100 EDGEWOOD, KY 41017 PHONE: 859-371-4555 FAX: 859-371-7540 I,_____________________________, wish to enter into the weight loss program directed by Dr. Gregory Weckenbrock. I understand this program includes diet, exercise, behavioral & lifestyle changes, and appetite suppressants when appropriate. I understand that the abuse or overuse of appetite suppressants is potentially life threatening and illegal. Appetite suppressants are controlled substances that are regulated by State and Federal Laws. I understand pursuant to State and Federal Laws prescriptions for controlled substances cannot be filled any sooner than once every four weeks. I understand I will not and cannot, for any reason, receive refills on prescriptions for appetite suppressants any earlier than once every four weeks. I understand that it is illegal to obtain appetite suppressants from more than one physician and agree I will not obtain any appetite suppressants from other prescribing physicians. I further understand it is illegal to use more than one pharmacy to have multiple prescriptions filled for appetite suppressants. If I choose to have my prescription filled outside of Figure Weight Loss and receive a written prescription, I also agree to use only one pharmacy in Kentucky to have the prescriptions filled. I agree to only participate in the weight management program directed by Dr. Gregory Weckenbrock. I understand it is illegal to participate in any other weight management program that uses appetite suppressants while I am participating in the weight management program directed by Dr. Gregory Weckenbrock. I understand that if I participate in the acquisition of appetite suppressants from multiple healthcare providers, for any reason, I am participating in an illegal action and may be held liable for criminal activity. Signature of Participant: _________________________________

Date

Witness: ______________________________________________

Date

5. Deceased patients. Our practice may release the PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs. 6. Organ and tissue donation. Our practice may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you’re an organ donor. 7. Research. Our practice may use and disclose your PHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your PHI for research purposes except when an Internal Review Board or Privacy Board has determined that the waiver of your authorization satisfies all of the following conditions: • The use or disclosure involves no more than a minimal risk to your privacy based on the following: (i) an adequate plan to protect the identifiers from improper use and disclosure; (ii) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); (iii) adequate written assurances that the PHI will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted; • The research could not practicably by conducted without thewaiver. • The research could not practicably by conducted without access to and use of the PHI. 8. Serious threats to health or safety. Our practice may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat. 9. Military. Our practice may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities. 10. National security. Our practice may disclose your PHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your PHI to federal and national security activities authorized by law. We also may disclose your PHI to federal officials in order to protect the president, other officials or foreign heads of state or to conduct investigations. 11. Inmates. Our practice may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for the purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution and/or, (c) protect your health and safety or the health and safety of other 12. Worker’s compensation. Our practice may release your PHI for workers compensation and similar programs. E. Your rights regarding your PHI: You have the following rights regarding the PHI that we maintain about you: 1. Confidential communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communications, you must make a written request to Gregory Weckenbrock, M.D. at 157 Barnwood Dr, Ste. 100, Edgewood, KY 41017 specifying the requested method of contact, or the location where you wish to be contracted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request. 2. Requesting restrictions. You have the right to request a restriction in our use of disclosure of your PHI for treatment, payment or health care operation. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment of your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise order to request a restriction in our use or disclosure of your PHI; you must make your request in writing to Gregory Weckenbrock, M.D., 157 Barnwood Dr., Ste. 100, Edgewood, KY 41017. Your request must describe in a clear and concise fashion:

• The information you wish restricted. • Whether you are requesting to limit our practice’s use, disclosure, or both. • To whom you want the limits to apply. 3. Inspection and copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Gregory Weckenbrock, M.D. at 157 Barnwood Dr., Ste. 100, Edgewood, KY 41017 in order to inspect and/or obtain a copy of your PHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews. 4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request for an amendment, your request must be made in writing and submitted to Gregory Weckenbrock, M.D. at 157 Barnwood Dr, Ste 100, Edgewood,KY 41017. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information in not available to amend the information. 5. Accounting of disclosures. All of our patients have the right to request and “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your PHI for purposes not related to treatment, payment or operations. Use of your PHI as a part of the routine patient care in our practice is not required to documented – for example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an “accounting of disclosures”, you must submit your request in writing to Gregory Weckenbrock, M.D. at 157 Barnwood Dr., Ste. 100, Edgewood,KY 41017. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request with a twelve (12) month period if free of charge, but our practice may charge you for additional lists within the same twelve (12) month period. Our practice will notify you of the costs involved with additional requests and you may withdraw your request before you incur any cost. 6. Right to a paper copy of this notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Gregory Weckenbrock, M.D. at 859-371-4555. 7. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, You must submit your complaint in writing to Gregory Weckenbrock, M.D. at 157 Barnwood Dr., Ste. 100, Edgewood, KY 41017. You will not be penalized for filling a complaint. 8. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note, we are required to retain records of your care. If you have any questions regarding this notice or our health information privacy policies, please contact Gregory Weckenbrock, M.D., 157 Barnwood Dr., Ste 100, Edgewood, KY 41017.

Sign: ______________________________________________ Date: ______________

NOTICE OF PRIVACY PRACTICES Effective Date:

September 2010

Gregory Weckenbrock, M.D. As required by the privacy created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This notice describes how health information about you (as a patient of this practice) may be used and disclosed and how you can get access to your individually identifiable health information. PLEASE REVIEW THIS NOTICE CAREFULLY A. Our commitment to your privacy: Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information or PH). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.

6. Health-related benefits and services. Our practice may use and disclose your PHI to inform you to health-related benefits or services that may be of interest to you. 7. Release of information to family/friends. Our practice may release your PHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter take their child to the pediatrician’s office for treatment of a cold. In this example, the babysitter may have access to this child’s medical information.

We realize that these laws are complicated, but we must provide you with the following Important information: • How we may use and disclosure your PHI • Your privacy right in your PHI • Our obligations concerning the use and disclosure of your PHI

8. Disclosures required by law. Our practice will use and disclosure your PHI when we are required to do so by federal, state, or local law.

The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that we create or maintain in the future. Our practice will post a copy of our current Notice in our office in a visible location at all times, and you may request a copy of our most current Notice at any time. B.

If you have questions about this Notice, please contact: Gregory Weckenbrock, M.D. at 859-371-4555

C. We may use and disclose your PHI in the following ways: The following categories describe the different ways in which we may and disclose your PHI. 1. Treatment. Our practice may use your PHI to treat you. For example, we may ask you to have laboratory tests & such as blood or urine tests, and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice – including, but not limited to, our doctor and nurses – may use or disclose your PHI in order to treat you or assist others in your treatment. Additionally, we may disclose your PHI to others who may also disclose your PHI to other health care providers for purposes related to your treatment. 2. Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits) and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to other health care providers and entities to assist in their billing and collection efforts. 3. Health care operations. Our practice may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning and entities to assist in their health care operations. 4. Appointment reminders. Our practice may use and disclose your PHI to contact you and remind you of an appointment. 5. Treatment options. Our practice may use and disclose your PHI to inform you of potential treatment options or alternative.

D. Use and disclosure of your PHI in certain special circumstances: The following categories describe unique scenarios in which we may use or disclose your identifiable health information. 1. Public health risks. Our practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of: • Maintaining vital records, such as births and deaths • Reporting child abuse or neglect • Preventing or controlling disease, injury, or disability • Notifying a person regarding a potential exposure to a communicable disease • Notifying a person regarding a potential risk for spreading or contracting a disease or condition • Reporting reactions to drugs or problems with products or devices • Notifying individuals if a product or device they may be using has been recalled • Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclosure this information if the patient agrees or we are required or authorized by law to disclose this information. • Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance. 2. Health oversight activities. Our practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions, civil administrative and criminal procedures or actions, or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general. 3. Lawsuits and similar proceeding. Our practice may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested. 4. Law enforcement. We may release your PHI if asked to do so by a law enforcement official: • Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement. • Concerning a death we believe has resulted from criminal conduct. • Regarding criminal conduct at our office. • In response to a warrant, summons, court order, subpoena, or similar legal process. • To identify/locate a suspect, material witness, fugitive or missing person. • In an emergency, to report a crime (including the location or victim(s) of the crime,or the description, identify or location of the perpetrator).