PATIENT WEIGHT LOSS CONSENT Protocol –

 

You are authorizing Indian Lake Medical Weight Loss & Wellness, Pllc to assist you in your current health and wellness, and weight loss efforts. You understand this attempt is a partnership, in that there must be open communication and that all follow up appointments must be kept or rescheduled in an effort to remain on track and successful. This  program may consist of, but not be limited to meal planning [calorie diets based on Basal Metabolic Rates, hCG diets, diabetic diets, nutritional coaching, ect.], regular exercise encouragement, instruction in behavior modification techniques,  and/or supplemental vitamin fat burner injections.

Your program may or may not involve the use of appetite suppressants. You must understand that if appetite suppressants are utilized, they may be used for durations exceeding those recommended in the medication package insert. Medication therapy is only prescribed at the discretion of the Advanced Nurse Practitioner. You are consenting that it is your choice to use these medication longer than the package insert and if you do choose to do so, it is at will.

You understand that many medical treatments involve risks as well as the proposed benefits. You also understand that there is certain health risks associated with remaining overweight. Risk of this program and the use of appetite suppressants, if in which this program applies to you, may include but are not limited to nervousness, restlessness, dry mouth, fatigue, elevated blood pressure, heart abnormalities, headaches and gastrointestinal irregularities. These and other possible risks could have long term effects and may be fatal. If this weight loss program for Indian Lake Medical Weight Loss & Wellness, Pllc does not apply to you – then please disregard.

You understand that risks associated with remaining overweight are tendencies to high blood pressure, diabetes, heart disease, arthritis of the joints, sleep apnea, depression, and possible sudden death. These risks may be modest if you am not significantly overweight but will increase with additional weight gain.

You understand that the success of the program will depend on you efforts, your follow up, and your body chemistry, and that there are no direct guarantees or assurances made for you directly to you that the program will be successful for you. You also understand that obesity may be a chronic, life-long condition that may require changes in eating habits and permanent changes in behavior to be treated successfully. This is generally a mental challenge, not a physical challenge.

You understand there are many significant health risks associated with obesity including, but not limited to: hypertension (high blood pressure), high cholesterol, blood vessel disease, thyroid, and other endocrine (hormonal) disorders. These diseases can result in heart attack, stroke, and can affect eyesight, kidney, lung, and brain functions along with many other serious results. These conditions require a level of ongoing care and management (called “continuity of care”) far beyond that of any wellness center. Therefore, the Indian Lake Medical is not a substitute for a patient having a “primary care” doctor.

We ask that patients have a “primary care” doctor to whom they can be referred for evaluation and management of blood pressure, diabetes, hypertension, and other medical problems. Please be advised that WHEN INDICATED, you may be prescribed a controlled substance in the form of an appetite suppressant that may raise your blood pressure. We accept patients with high blood pressure if they are on blood pressure medication and their blood pressure is under control. Patients are advised not to take any controlled substance such as Phentermine or Adipex if their blood pressure is higher than 140/90. If a patient has a high reading, a blood pressure over 140/90, you will NOT be prescribed Phentermine or Adipex, or SR Combo.

Indian Lake Medical also offers other programs including the Lipotropic Fat Burner Injections, Tablets as well as Nutritional counseling, HCG, Hormone therapy, etc. – each all offered on an individual basis after patient assessment.   You understand that Phentermine/SR Combo, if prescribed, will be dispensed from Indian Lake Weight Loss & Wellness, Pllc in order to ensure quality and efficacy. Because of the nature of weight loss in general, the partnership dynamic, and the effort needed to make both ends meet the middle, you must understand that Indian Lake Medical Weight Loss & Wellness, Pllc will make every effort possible help you meet your weight loss goals, as we are the Metabolism Experts. Indian Lake Medical Weight Loss & Wellness, Pllc does not offer refunds on any services or products, including time and pharmaceuticals, rendered.

At the time of service you agree to commit to being financially responsible for payment of your office visits and additional products at the time of service unless some other payment arrangement is agreed upon with the management of Indian Lake Weight Loss & Wellness, Pllc. You understand that refunds are never given under any circumstances.

I have read and understand the above. You are authorizing to give your consent to T. Taylor Minchey, Nurse Practitioner and her assistants to help me in my weight reduction efforts. I understand that it is my responsibility to follow the instructions carefully and to timely report to Indian Lake Medical Weight Loss & Wellness any significant medical problems that I think may be related to my weight loss program. If I develop side effects from the diet or medications, I will discontinue the weight loss program and seek medical treatment at the nearest emergency room or contact my primary care doctor. Again, you understand that Indian Lake Medical Weight Loss & Wellness, Pllc does not offer refunds on any services or products, including time and pharmaceuticals, rendered.

I understand that I must provide T. Taylor Minchey, Nurse Practitioner and her assistants my medical history including all medications that I currently take. I also understand that I must update this information if it changes.

I acknowledge that I understand the risks of the proposed treatment and the medical staff of Indian Lake Weight Loss & Wellness, Pllc has answered all of my concerns regarding my care.

 

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