SERVICE AGREEMENT FORM - Orland Park, IL

SERVICE AGREEMENT
Your Name *
Date *

Month Day Year
This agreement is entered into effect on {date23} by an affiliate that DBA Options Medical Weight Loss “Provider” and, {yourName} "Client."
1. Programs may be cancelled within 72 business hours of start date. If a program is cancelled within the 72 hours, the client will pay retail rate for any services utilized. All remaining funds paid by client will be refunded once necessary items are returned. Any dispensed medications and/or injections taken out of clinic may not be returned. If a program is finished, all remaining products/services* must be used within one year from program start date, or they will expire and Initial will be voided from the account.
Initials *
2. Client understands that all Options Diet System products, sauces, bio-box, and additional HCG supplies are an extra cost and not included in any package.
Initials *
3. *All weight loss counseling sessions must be completed in consecutive weeks aligning with the Options Diet System Program chosen, or any missed sessions will be lost.
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4. All packages cover initial medication. If additional medication is needed above the normal prescription, client is responsible for a charge of $1 per pill for the additional medication. Time-released Phendimetrazine, Diethylpropion and Phentermine/Topiramate are considered above a normal prescription and requires additional charges.
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5. Client must complete blood work within the first two weeks in order to refill medication. Client may not eat 12 hours prior to completing blood work. Water is permitted. If a client does not fast and is denied medication due to blood work results, the client will be responsible for the cost of another test.
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6. There is a $15 fee for late payments. After 60 days of an account being in default, a letter will be sent and client will have 30 days to pay remaining balance in full. If not paid, the client's account will be turned over to a third party to collect any remaining balance
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7. Client must give a 24 hour notice to cancel or reschedule appointments. If a counseling session is cancelled within 24 hours the client will be charged for that session. If client is over 15 minutes late to an appointment they will be able to weigh in, get an injection, and pick up food; however, this will not be done by the counselor due to scheduling conflicts. A session will still be charged for that day. If a provider visit is cancelled within 24 hours, a $20 fee may be applied.
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8. Counselors are only available during business hours and will not respond while the clinic is closed. If the issue is time sensitive please contact the answering service during off hours and inform them your issue is time sensitive.
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9. Monthly medication packages come with a specific amount of provider visits. Each additional visit will be a charge of $59 unless the appointment was set by the provider to follow up for any reason besides dispensing medication.
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10. All Options Diet System Products may only be returned to provider if the package or bottle is sealed, a credit will be applied, to the clients options account. All products must be returned within 30 days of original purchase for store credit.
Initials *
Client Signature: *

Clear
Date: *

Month Day Year

CLIENT INFORMED CONSENT
This Informed Consent Form is intended to give fair notice of the requirements of clients seeking to participate in the HCG Diet Program at office affiliate that DBA OPTIONS MEDICAL WEIGHT LOSS, to fully disclose any risks associated with participation in the HCG Diet program, and to obtain written “Informed Consent” from the client to undergo treatment by health care professionals associated with the above stated clinics.

History of HCG for Weight Loss

Although the HCG diet has gained popularity in the past few years, the HCG diet dates to the 1950s. Columbia University explains that British doctor Albert T. Simeons was the first medical physician to experiment with HCG for dieting purposes. {1} Papers on the Simeons therapy have been published regularly since 1954. The Simeons therapy is a slimming therapy in which the patient, over a period of 3.5 to 6 weeks, keeps to a fat-free diet of 500 kilo-calories (kcal) day, as prescribed by Simeons. At the same time the patient receives daily an intramuscular injection of 125 International Units (iu) of human chorionic gonadotropin (HCG HCG is a hormone that occurs in the body in large quantities during pregnancy. It is obtained from the urine of pregnant women and is used to make a drug for the treatment of certain infertility problems Simeons developed the therapy on the basis of his experience of using HCG to treat young boys suffering from (Dystrophia adiposito- genitalis It is claimed that overweight patients who follow the Simeons therapy will a) lose weight quickly, b) not feel weak, c) not be hungry, and d) lose fat from those parts of the body where it tends to remain longest during normal dieting (i.e. stomach, hips, thighs, upper arms

The American FDA Requires the Following Disclaimer

“HCG has not been demonstrated to be effective adjunctive therapy in the treatment of obesity. There is no substantial evidence that it increases weight loss beyond that resulting from caloric restriction, that it causes a more attractive or ‘normal’ distribution of fat, or that it decreases the hunger and discomfort associated with calorie-restricted diets”;

Allergic Responses and Important Information

{2} You should not use this medication if you have ever had an allergic reaction to HCG, or if you have:
- Early puberty (also called precocious puberty); or a hormone-related cancer (such as prostate cancer Before receiving HCG tell your doctor if you are allergic to any drugs or if you have:
- a thyroid or adrenal gland disorder;
- an ovarian cyst;
- premature puberty;
- cancer or a tumor of the breast, ovary, uterus, prostate, hypothalamus, or pituitary gland;
- undiagnosed uterine bleeding;
- heart disease;
- kidney disease;
- epilepsy;
- migraines; or
- asthma.
If you have any of these conditions, you may need a dose adjustment or special tests to safely use HCG.

{1} BR J Clin Pharmacol 1995; 40: 237-243 {2}Reference {https://www.drugs.com/hcg.html}

HCG Side Effects
Stop using HCG and get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Call your doctor at once if you have any of these signs of a blood clot: pain, warmth, redness, numbness, or tingling in your arm or leg; confusion, extreme dizziness, or severe headache.

Some women using this medicine have developed a condition called ovarian hyperstimulation syndrome (OHSS), especially after the first treatment cycle. OHSS can be a life-threatening condition. Call your doctor right away if you have any of the following symptoms of OHSS
- severe pelvic pain;
- swelling of the hands or legs;
- stomach pain and swelling;
- shortness of breath;
- weight gain;
- diarrhea;
- nausea or vomiting; or
- urinating less than normal.
HCG can cause early puberty in young boys. Call your doctor if a boy using this medicine shows early signs of puberty, such as a deepened voice, pubic hair growth, and increased acne or sweating.

Less serious side effects may include:
- headache;
- feeling restless or irritable;
- mild swelling or water weight gain;
- depression;
- breast tenderness or swelling; or pain,
  swelling, or irritation where the injection is given.
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Pregnancy and Breast Feeding

Although HCG can help you become pregnant, this medication is in the FDA pregnancy category X. This means that using this medication or any other weight loss prescriptions we prescribe once you are pregnant can cause birth defects in the baby. Do not use HCG or any other obesity medications prescribed to you while on our program if you are pregnant. Tell your doctor right away if you become pregnant during treatment. It is not known whether HCG passes into breast milk. Do not use HCG without telling your doctor if you are breast-feeding a baby.
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What other Drugs Will Affect HCG

There may be other drugs that can interact with HCG. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor.

Mandatory Adherence to Diet Protocol

This affiliate office that DBA OPTIONS MEDICAL WEIGHT LOSS mandates that the diet protocol is adhered to exactly. Since the program is diet related and completed off site, this affiliate office that DBA OPTIONS MEDICAL WEIGHT LOSS does not guarantee results. Results may vary from client to client.

MEDICATION RELEASE FORM
By signing this form, I certify that I received client education and verbal counseling information on one or more of the following drugs:

Phentermine Hydrochloride Phendimetrazine Tartrate Diethylpropion Hydrochloride Hydrochlorothiazide Phentermine/Topiramate Metformin Human Chorionic Gonadotropin (HCG)
I understand that it is in my best interest to read and understand the material I have received. I furthermore do not hold Options Medical Weight Loss LLC or any affiliate that DBA as Options Medical Weight Loss or any of its practitioners responsible if I do not read or follow the instructions for taking any of these drugs. I also understand that I must take the prescribed medication as instructed by the medical provider
Client Signature: *

Clear
Date: *

Month Day Year
Should be Empty:

SERVICE AGREEMENT

CLIENT INFORMED CONSENT

HCG Side Effects

Pregnancy and Breast Feeding

What other Drugs Will Affect HCG

Mandatory Adherence to Diet Protocol

MEDICATION RELEASE FORM