Medical Weight Loss Consent Form PATIENT INFORMATION Name * First Name Last Name Cell Phone Email * Date of Birth: MM DD YYYY 1. Understanding of the Program: The medical weight loss program may include dietary counseling, exercise recommendations, prescription medications,medical assessments, and/or other interventions to support weight loss. The specifics of your weight loss plan will be discussed with you and tailored to your health goals, current medical conditions, and individual needs. When necessary, medications may be used to assist in weight loss to decrease obesity-related risk factors and help further with weight maintenance. Medication will be chosen based on past experience with weight loss drugs, potential side effects and how that may affect know health conditions, current medications already taking, risk vs benefit, etc. You may not qualify or meet safety criteria for the medication you want to try. Your provider will discuss options with you one-on-one and make customized recommendations for you. 2. Risks and Benefits: While medical weight loss programs can be effective in achieving weight loss, they may not work for everyone, and results may vary. As with any medical treatment, there are potential risks, including but not limited to: • Side effects from medications (e.g., nausea, dizziness, fatigue, constipation, diarrhea) • Nutritional imbalances or deficiencies • Increased risk of gallstones during rapid weight loss • Emotional or psychological effects related to weight loss or body image changes By signing this consent form, you acknowledge that you have discussed these potential risks with your healthcare provider and understand them. 3. Medical Assessment: Before starting the medical weight loss program, you will undergo an initial medical assessment to evaluate your overall health and identify any underlying conditions that may impact your ability to safely lose weight. This may include blood tests, physical exams, and a review of your medical history. 4. Medications: The weight loss program may involve prescription medications designed to aid weight loss and to decrease obesity-related risk factors. These medications are prescribed based on a thorough evaluation of your health and are intended to complement lifestyle changes, such as diet and exercise. Medication will be chosen based on past experience with weight loss drugs, potential side effects and how that may affect know health conditions, current medications already taking, risk vs benefit, etc. You may not qualify or meet safety criteria for the medication you want to try. Your provider will discuss options with you one-on-one and make customized recommendations for you. These medications may include: • GLP-1 meds such as compounded Semaglutide and Tirzepatide or branded Wegovy and Zepbound • Phentermine • Naltrexone/Wellbutrin • LipoStat+ Injection (Methionine, Inositol, Choline, B6 & B12) • Other known peptides that safely aid in weight loss You acknowledge that you will follow the prescribed regimen and inform your healthcare provider of any side effects or concerns during the course of treatment. 5. Lifestyle Modifications: A key component of the medical weight loss program is making lasting changes to your diet and physical activity levels.You agree to actively participate in the recommended lifestyle modifications and to attend scheduled follow-up appointments to monitor progress. 6. Confidentiality: All personal and medical information shared during the course of the program will be kept confidential in accordance with privacy laws and regulations. This includes your medical history, test results, and any discussions with your healthcare provider. 7. Voluntary Participation: Participation in the medical weight loss program is voluntary, and you have the right to withdraw from the program at any time. If you choose to withdraw, you may do so without penalty or negative consequences, although your healthcare provider will discuss the potential impact of discontinuing the program and give instructions to safely taper medications if necessary. 8. Financial Responsibility: You acknowledge that you are responsible for any fees associated with the medical weight loss program, including but not limited to consultations, medical treatments, medications, and follow-up visits. You agree to provide accurate information regarding your insurance and payment options and to fulfill any financial obligations in a timely manner. 9. Consent to Treatment: By signing below, you consent to participate in the medical weight loss program, understand the risks and benefits, and agree to follow the treatment plan as discussed with your healthcare provider. Date MM DD YYYY Signature Thank you for filling out your information!
