Phentermine Consent 

 I request the use of Phentermine, along with strict dietary restrictions for the purpose of weight loss. I understand that as part of the program, I will be given a limited physical, orientation to the program with supporting materials and I will be instructed on how to administer Phentermine myself. I understand that initial blood tests may be necessary to rule out any conditions that would disqualify me from the program. I will obtain these from my own physician or have them ordered through Padgett Medical for an additional fee.

             I understand there is no guarantee for the effectiveness of Phentermine. I agree that I am and will be under the care of another medical provider for all other conditions.  Our doctor at Padgett Medical Center can work in conjunction with, but cannot replace, my regular primary care physicians, such as general practitioners or other specialists in family medicine or internal medicine. I understand our doctor at Padgett Medical Center can only prescribe Phentermine and medication necessary for this treatment and all other health matters should be through my regular physician(s).

             Prior to my treatment, I have fully disclosed any medical conditions or diseases such as history of gallbladder disease, diabetes, autoimmune diseases, HIV, heart disease, liver disease, kidney disease, uncontrolled high blood pressure, seizure disorders, blood disorder (anemia, thalassemia, hemophilia, etc.) emphysema or asthma, and any history of stroke or cancer. These contraindications have been fully discussed with me. Further contraindications are outlined below. If I fail to disclose any medical condition that I have, I release the doctor and facility from any liability associated with this procedure.

             I understand that it is my responsibility to inform our doctor at Padgett Medical Center if I am pregnant, if I am trying to become pregnant or if I become pregnant during the course of these treatments.  I agree to immediately report any problems that might occur to my medical provider during the treatment program. I further understand that not complying with the dosage recommendations and dietary restrictions could increase risks and alter my results from the program. If I do not follow these recommendations and restrictions, I agree to release the doctor and facility from any liability arising as a result of this. I understand that I may quit the program at any time. While adverse side effects or complications are not expected, in the event that an illness does occur, I understand that if I experience an emergency situation, I understand that I need to go to an emergency facility right away. I understand I also need to contact Padgett Medical Center to inform them of the situation.

             I understand Phentermine treatments may involve these risks and other unknown risks.

             I understand that use of Phentermine is absolutely contraindicated during pregnancy and breastfeeding.

             I understand that if there are any changes in my medical history or there are any changes in my medications or any other changes relevant to this procedure, I will advise our doctor at Padgett Medical Center at that time.

             I agree for my before and after photos to be used in advertising, social media, or other networks; and my face will not be shown, only body pictures will be used.

             I understand that complete patient confidentiality will be maintained at all times.

PHENTERMINE INFORMED CONSENT CONT.

Instructions: Initial each of the following statements to show you understand and agree with them.

Contraindications

             Patients with the following should not use Phentermine: Check the box next to all that apply to you)

•       History of cardiovascular disease (e.g., coronary artery disease, stroke, arrhythmias, congestive heart failure, uncontrolled hypertension)

•       During or within 14 days following the administration of monoamine oxidase inhibitors

•       Hyperthyroidism

•       Glaucoma

•       Agitated states

•       History of drug abuse

•       Pregnancy

•       Nursing

•      Known hypersensitivity, or idiosyncrasy to the sympathomimetic amines

Warnings/Precautions

             Patients taking Phentermine should be aware of the following risks. If any of the following occur, discontinue use and contact your doctor immediately.

•       Coadministration with other drugs for weight loss is not recommended (safety and efficacy of combination not established).

•       Rare cases of primary pulmonary hypertension have been reported. Phentermine should be discontinued in case of new, unexplained symptoms of dyspnea, angina pectoris, syncope or lower extremity edema.

•       Rare cases of serious regurgitant cardiac valvular disease have been reported.

•       Tolerance to the anorectic effect usually develops within a few weeks. If this occurs, phentermine should be discontinued. The recommended dose should not be exceeded.

•       Phentermine may impair the ability of the patient to engage in potentially hazardous activities such as operating machinery or driving a motor vehicle.

•       Risk of abuse and dependence. The least amount feasible should be prescribed or dispensed at one time in order to minimize the possibility of overdosage.

•       Concomitant alcohol use may result in an adverse drug reaction.

•       Use caution in patients with even mild hypertension (risk of increase in blood pressure).

•      A reduction in dose of insulin or oral hypoglycemic medication may be required in some patients.

             Patients who are taking insulin may need an alteration in their current dosage. Please check with             your current doctor.

Adverse Reactions

             The following adverse reactions are described, or described in greater detail, in other sections:

•       Primary pulmonary hypertension

•       Valvular heart disease

•       Effect on the ability to engage in potentially hazardous tasks

•       Withdrawal effects following prolonged high dosage administration

PHENTERMINE INFORMED CONSENT CONT.

Instructions: Initial each of the following statements to show you understand and agree with them.

             The following adverse reactions to phentermine have been identified:

Cardiovascular

Primary pulmonary hypertension and/or regurgitant cardiac valvular disease, palpitation, tachycardia, elevation of blood pressure, ischemic events

Central Nervous System

Overstimulation, restlessness, dizziness, insomnia, euphoria, dysphoria, tremor, headache, psychosis

Gastrointestinal

Dryness of the mouth, unpleasant taste, diarrhea, constipation, other gastrointestinal disturbances

Allergic

Urticaria

Endocrine

Impotence, changes in libido

Drug Interactions

             The following interactions with phentermine have been identified:

Monoamine Oxidase Inhibitors

Use of phentermine is contraindicated during or within 14 days following the administration of

monoamine oxidase inhibitors because of the risk of hypertensive crisis.

Alcohol

Concomitant use of alcohol with phentermine may result in an adverse drug reaction.

Insulin and Oral Hypoglycemic Medications

Requirements may be altered.

Adrenergic Neuron Blocking Drugs

Phentermine may decrease the hypotensive effect of adrenergic neuron blocking drugs.

Interactions

             Patients may be at risk for a hypertensive crisis, if taking Phentermine while on an MAOI.

             Taking phentermine is not recommended for those currently taking: Check all that apply to you.

-  Concomitant weight loss drugs, including SSRIs

- Fluoxetine

-  Sertraline

-  Fluvoxamine

- Paroxetine

             Patients with the following should take special precautions and consult their doctor before using             Phentermine: Check all that apply to you

-Allergies to medicines, foods, or other substances

-Have a brain or spinal cord disorder

-Hardening of the arteries

-High blood pressure

- Diabetes

- High cholesterol or lipid level

             Phentermine may decrease hypotensive effect of guanethidine.

            By signing below, I agree I have read and fully understand the above terms. All my questions have been addressed to my satisfaction. I agree to release the doctor and the facility from any liability associated with this procedure. In the event a dispute arises over the outcome of the procedure, I consent solely to arbitration as a legal means of settlement.

HCG Consent Form 

I request injections of HCG along with strict dietary restrictions for the
purpose of weight loss. I understand that as part of the program, I will be
given a limited physical, orientation to the program with supporting
materials and I will be instructed on how to administer the injections myself.
I understand that initial blood work may be necessary to rule out any
conditions that may disqualify me from the program, but is not required. If
needed I can order these tests through my primary care physician, or
through the physician at Padgett Medical Center for an additional fee. I
understand that HCG is not FDA approved for weight loss as this application
is considered “off-label use.” I understand there is no medical evidence to
support the use of HCG for this purpose. I agree that I am and will be under
the care of another medical provider for all other conditions. Physicians at
Padgett Medical Center can work in conjunction with, but cannot replace, my
regular primary care physicians, such as general practitioners or other
specialists in family medicine or internal medicine. I understand our
physicians at Padgett Medical Center can only prescribe HCG and medication
necessary for this treatment and all other health matters should be through
my regular physician(s).
Prior to my treatment, I have fully disclosed any medical conditions or
diseases such as pregnancy, trying to become pregnant, breastfeeding,
history of gallbladder disease, diabetes, autoimmune diseases, HIV, heart
disease, liver disease, kidney disease, uncontrolled high blood pressure,
seizure disorders, blood disorders (anemia, thalassemia, hemophilia, etc.)
Emphysema or asthma, and any history of stroke or cancer. These
contraindications have been fully discussed with me. If I fail to disclose any
medical condition that I have, I release the doctor and facility from any
liability associated with this procedure.
While HCG is generally free of negative side effects, there is the possibility of the
following:
● Abnormal enlargement of
● breasts in men (gynecomastia)
● Acne
● Arterial Thromboembolism-
● another potential life-
● threatening condition
● Blood Clots
● Changes in mood
● Collapse
● Death
● Difficulty breathing
● Excessive fluid retention in the body
● tissues, resulting in swelling (edema)
● Hair loss
● Irregular Menses
● Irritation or skin rash in the area of use
● Migraine Exacerbation
● Ovarian Hyperstimulation syndrome
● (OHSS)- which is a life-threatening
● condition
● Overstimulation of the ovaries causing
● production of many ova (eggs) in
● women
● Prostate hypertrophy
● Rare Allergic Reaction
● Risk of multiple pregnancies (twins,
● triplets, quadruplets, etc.)
● Tiredness
I understand there may be a reaction with the medication Antagon (Ganirelix).
I understand HCG treatments may involve these risks and other unknown risks.
I understand that I will need to stop the HCG injections during my period
(menstruation).
I understand that the use of HCG is absolutely contraindicated during pregnancy and
breastfeeding. I understand it is my responsibility to inform Padgett Medical Center if I
am pregnant if I am trying to become pregnant during the course of these treatments.
I understand that HCG. Multiple birth control methods should be used while on HCG.
Therefore, I agree to use condoms and/or abstinence as a birth control method for the
duration of the diet.
I understand that I may quit the program at any time. While adverse side effects or
complications are not expected, in the event that an illness does occur, I understand
that I need to contact Padgett Medical Center immediately. I understand if I experience
an emergency situation, I understand that I need to go to an emergency facility.
I understand that if there are any changes in my medical history or there are any
changes relevant to this procedure, I will advise the staff at Padgett Medical Center at
that time.
I agree for my before and after photos to be used in advertising, social media, or other
networks; and my face will not be shown, only body pictures will be used.
I have read and fully understand the above terms. All my questions have been
addressed to my satisfaction. I agree to release the doctor and the facility from any
liability associated with this procedure. In the event a dispute arises over the outcome
of the procedure, I consent solely to arbitration as a legal means of settlement.

HIPAA Release of Information Authorization Form

Patient authorizes Padgett Medical Center, LLC to request any and all medical records, x-rays, or any diagnostic testing results from any and all medical providers involved in my medical care past or present. Please forward any and all documents requested to the attention of the provider at this fax number below.

Tampa office Fax (813) 908-7711

Ocala office Fax (352) 369-0107

By signing this authorization, I understand that medical records released may contain
information related to HIV status, aids, sexually transmitted diseases, mental health, and alcohol abuse, etc. I understand that release of psychotherapy notes requires additional authorization. NOTE: If the information you are authorizing for release by signing this form involves alcohol or drug abuse, you must also sign a special authorization that is separate from this one, alcohol and drug abuse information is protected by federal law (FEDERAL REGULATIONS 42 CFR PART 2) and will not be shared with anyone else unless you sign a separate form.

{name}

{dateOf}

I understand that Padgett Medical Center, LLC is using information which I am providing about my blood pressure and current health conditions to provide medical services. I agree to provide accurate information to the best of my knowledge. In the event that I experience medical complications due to my blood pressure or other medical history that was not properly disclosed to Padgett Medical Center, LLC, I assume full responsibilty for all health conditions that may arise. I agree to hold Padgett Medical Center, LLC, all staff, physicians, and mid-level providers harmless. I release all liability from Padgett Medical Center, LLC for any adverse medication reactions that may arise. I understand that temporary provisions allow services to be completed via telemedicine. I understand that future visits I will be required to visit in person and complete any necessary testing as requested by medical providers.

I understand that due to current state of emergency in Florida, Padgett Medical Center is following guildelines with prescribing medications for weight loss. At this time, Padgett Medical Center is unable to do a new EKG with telemedicine patients. Patient agrees to disclose any current heart conditions and consents to stimulant medicaitions including but not limited to phentermine, phendimetrazine, diethylpropion, ECA stack, or similar medication without an EKG. Patient assumes full responsibility for any health complications that may results from using medications without a current EKG. Patient agrees to hold Padgett Medical Center, LLC, all staff, physicians, mid-level providers, employees, and contractors harmless for any health complications that could arise.