Weight Loss Consent for Appetite Suppressants & B-12 Lipo Injections REQUIRED LABSI understand that I must have my labs drawn at the clinic or I must provide a copy of my labs to Beach Medical that have complete test results for: Metabolic Panel (CMP), Lipid Panel, and Thyroid (TSH). Labs must be drawn or a current copy (drawn within the last year) must be submitted before I can receive a refill of my medication. HIPPA POLICYI have received/reviewed a copy of the HIPPA privacy notice. FINANCIAL POLICYThank you for selecting Beach Medical Wellness, LLC for your health care. We are honored to be of service to you and your family. This is to inform you of our payment requirements and financial policy. Please be advised that payment for all services will be due at the time services are rendered. For your convenience, we accept Visa, MasterCard, Amex, Discover, Cash, and HSA/FSA. You may use your services rendered receipt to file independently to your health insurance if you have weight-loss coverage. We do not accept insurance payments.
INFORMED CONSENT for APPETITE SUPPRESSANTS:I understand and acknowledge that treatment by Beach Medical Wellness, LLC, Dr. Melissa Pearce, MD and their designated assistants is limited solely to assistance with weight reduction efforts. This treatment does not provide a substitute or replacement for any regular physician. Beach Medical Wellness, LLC and Dr. Melissa Pearce, MD do not treat acute or chronic medical problems, and I agree to see my regular physician for these problems.
I authorize Dr. Melissa Pearce, MD and whomever she designates as her assistants to assist me in my weight reduction efforts. I understand my treatment may involve but is not limited to the use of appetite suppressant medications for more than 12 weeks and, when indicated, in higher doses than the dose indicated in the appetite suppressant labeling. I understand that my program may consist of a balanced diet, a regular exercise program, instructions in behavior modification techniques, B12 injections, and may involve the use of appetite suppressant medications.
“Medications, including appetite suppressants, have labeling worked out between the makers of the medication and the Food and Drug Administration. This labeling contains, among other things, suggestions for using the medication. The appetite suppressant labeling suggestions are generally based on shorter-term studies (up to 12 weeks) using the dosages indicated in the labeling.”
“As a physician, I have found the appetite suppressants helpful for periods far more than 12 weeks, and at times in larger doses than those suggested in the labeling. As a physician, I am not required to use the medication as the labeling suggests, but I do use the labeling as a source of information along with my own experience, the experience of my colleagues, recent longer-term studies and recommendations of university-based investigators. Based on these, I have chosen, when indicated, to use the appetite suppressants for longer periods of time and at times, in increased doses.”
“Such usage has not been as systematically studied as that suggested in the labeling and it is possible, as with most other medications, that there could be serious side effects (as noted below).”
“As a physician, I believe the probability of such side effects is outweighed by the benefit of the appetite suppressant use for longer periods of time and when indicated in increased doses. However, you must decide if you are willing to accept the risks of side effects, even if they might be serious, for the possible help the appetite suppressants use in the manner may give.”
I understand it is my responsibility to follow the instructions carefully and to report to the doctor treating me for my weight any significant medical problems that I think may be related to my weight control program as soon as reasonably possible.
I understand the purpose of this treatment is to assist me in my desire to decrease my body weight and maintain this weight loss. I understand my continuing to receive the appetite suppressant will be dependent on my progress in weight reduction and weight maintenance.
I understand there are other ways and programs that can assist me in my desire to decrease my body weight and to maintain this weight loss. In particular, a balanced calorie counting program or an exchange eating program without the use of the appetite suppressant would likely prove successful if followed, even though I would probably be hungrier without the appetite suppressant.
RISKS OF PROPOSED TREATMENT:
understand this authorization is given with the knowledge that the use of the appetite suppressants for more than twelve weeks and in higher doses that the dose indicated in the labeling involves some risks and hazards. The more common include: nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, psychological problems, medication allergies, high blood pressure, rapid heartbeat and heart irregularities. Less common, but more serious risks are primary pulmonary hypertension and valvular heart disease. These and other possible risks could, on occasion, be serious or fatal. I understand that if I have questions or concerns about side effects or risks, or if I prefer to see the Medical Director for my evaluation and care, the Medical Director is available by appointment for these purposes.
I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I also understand that I will have to continue watching my weight all my life if I am to be successful in maintaining any weight loss achieved.
I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained, or any questions I have concerning them have not been answered to my complete satisfaction. I have been urged to take all the time I need in reading and understanding this form and in talking with my doctor regarding risks associated with the proposed treatment and other treatments not involving appetite suppressants. I also understand that participation in this program is strictly voluntary and it is my choice to participate or not. I understand that I may discontinue this treatment at any time at my discretion.
WOMEN ONLY CONSENT:
I understand that Phentermine and other anorectic medications should NOT be taken during pregnancy due to the chance of adverse effects to the baby. The medications have been fully explained to me and I am aware of the risks involved. To the best of my knowledge, I am not pregnant. I am aware of the precautions that should be taken to avoid pregnancy while I am on the medication. If I become pregnant, I will advise both Beach Medical Wellness, LLC AND my OB/GYN immediately.
IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THE PROPOSED TREATMENT, OR ANY QUESTIONS WHATSOEVER CONCERNING THE PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK YOUR DOCTOR NOW BEFORE SIGNING THE CONSENT SIGNATURE FORM.
I have read and fully understand this consent form. I realized I should not sign this form if all items have not been explained to me. My questions have been answered to my complete satisfaction. I have been urged and have been given all the time I need to read and understand this form.
(If you have any questions as to the risks or hazards of the proposed treatment, or any questions whatsoever concerning the proposed treatment or other possible treatments, ask your doctor now before signing the consent signature form.)
INFORMED CONSENT for SEMAGLUTIDE:Mounjaro (tirzepatide), Wegovy/Ozempic (semaglutide), Rybelsus (semaglutide tablet), Trulicity (duraglutide), Saxenda (liraglutide)
The following consent forms apply to the above GLP-1 receptor medications and variations received through both commercial and compound pharmacy.
As of January 1st, 2023, only Wegovy has been approved by the FDA as an anti-obesity treatment. Therefore, other options/forms are considered "off-brand" use when used for weight-loss. Semaglutide prescriptions received from a compound pharmacy (or not a name brand listed above) are not an FDA approved treatment.
A BMI of ≥ 27 with at least one weight-related comorbid condition OR a BMI of ≥ 30
No previous history of Type 1 diabetes, pancreatic, kidney, thyroid, or liver disease.
Labwork within 1 year including: CMP, TSH, Lipid Panel, optional HbA1C required before refill
If you take birth control pills by mouth, it may not work as well while using these medications.
Do not use if you or any of your family have ever had medullary thyroid carcinoma (MTC).
Do not use if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
Do not use while pregnant or planning for pregnancy. Do not use if you have a history of suicidal thoughts or ideation.
The most common side effects include: nausea, diarrhea, decreased appetite, vomiting, constipation, indigestion, and stomach (abdominal) pain. These medications may cause tumors in the thyroid, including thyroid cancer. Pancreatitis, hypoglycemia, kidney problems, allergic reactions, changes in vision, stomach and gallbladder problems are also potential side effects.
Watch for possible symptoms, such as a lump or swelling in the neck, hoarseness, trouble swallowing, severe abdominal pain or shortness of breath.
INFORMED CONSENT FOR SUBLINGUAL SEMAGLUTIDE
Pharmacy Innovations now offers a compounded sublingual form of Semaglutide to help aid in weight loss.
When combined with a healthy diet and exercise, sublingual Semaglutide may help reduce appetite and cravings, improve blood sugar control, and aid in weight loss.
The sublingual form of Semaglutide is a convenient option for patients who may have difficulty with injections. It is placed under the tongue and absorbed into the bloodstream, making it an attractive option.
As with any medication, it is important to discuss with your healthcare provider to determine if sublingual Semaglutide is appropriate for you. Pharmacy Innovations can work with your healthcare provider to create a personalized treatment plan that meets your needs.
I am aware that sublingual medications have disadvantages. Eating, drinking, or smoking, can affect how the drug is absorbed and how well it works. Any open sores in your mouth can also become irritated by the medication. I understand it is required of me to provide a FOUR WEEK food log to Beach Medical Wellness, LLC to aid in the efficacy of the sublingual semaglutide drops. I understand that research has not proven the efficacy of the sublingual semaglutide drops and that adverse reactions could occur or results may vary.
I certify that I have read this entire informed consent and that I understand and agree to the information in this form. I certify that I am a competent adult of at least 18 years of age, or that if I am a minor under the age of 18, I understand that the consent of my parent/legal guardian will also be required for treatment. This informed consent is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns. No guarantees, warranty or assurance has been made as to the treatment results.
I will hold, Beach Medical Wellness, LLC, it’s owner(s), agents, providers, employees and shareholders completely harmless from all and any litigation or claims made, should I have any adverse reactions to the sublingual semaglutide drops. Further, I hold Beach Medical Wellness, LLC completely harmless from any and all malpractice suits or claims made in relation to my receiving sublingual semaglutide drops. All complications should be seen in the emergency room or by your local physician. No clinical follow-up is provided by the provider. Beach Medical Wellness, LLC and its providers maintain the right, under all circumstances and without penalty, to not perform the procedure should the decision be made by them.
Payment and Cancellation Policy: I understand that refunds will not be processed after medications have shipped. I understand Beach Medical Wellness, LLC will help to find an alternative medication in the event the sublingual semaglutide drops are not effective.
This agreement is non-transferable and may not be altered by anyone without the express written consent of the provider. This agreement does not expire.
INFORMED CONSENT for VITAMIN B-12 LIPOTROPIC INJECTIONS:Vitamin B-12 helps maintain good health and has been shown to be beneficial in helping to: Reduce stress, fatigue, improve memory and cardiovascular health, and maintain a good body weight. It can also assist the body in converting proteins, fats and carbohydrates into energy and is necessary for healthy skin and eyes. Amino Acids help the liver to cleanse the body of toxins and assist the body in metabolizing fat and cholesterol. They may also be helpful in reducing fatigue and the symptoms of allergies.B12 and Amino Acid Injections are better absorbed by the body since they go directly into the blood stream. Alternatives to these injections are oral vitamins which are supplied in-office for purchase.
B12 and Amino Acid Injections common side effects include but are not limited to:
Risks: I understand there is risk of mild diarrhea, upset stomach, nausea, a feeling of pain and a warm sensation at the site of the injection, a feeling, or a sense, of being swollen over the entire body, headache and joint pain.If any of these side effects become severe or troublesome I will contact my physician immediately.I understand that although rare Vitamin B12 and Amino Acid injections can result in serious side effects. Although this is a relatively rare occurrence, anyone taking vitamin B12 or Amino Acid injections should be aware of the possibility. Uncommon side effects are much more serious than the common side effects of B12 and Amino Acid injections, and such side effects should be reported to a physician to be evaluated for seriousness. Uncommon and dangerous side effects include:Rapid heartbeat, chest pain, heart palpitations, flushed face, restlessness, muscle cramps and weakness, difficulty breathing and swallowing, dizziness, confusion, rapid weight gain, tight feelings in the chest, hives, skin rashes, shortness of breath when there is no physical exertion and unusual wheezing and coughing.Before starting vitamin B12 or Amino Acid injections I will make sure to tell my Physician if I am pregnant, lactating or have any of the following conditions:Leber’s Disease, Kidney disease, Liver disease, An infection, Iron deficiency, Folic acid deficiency, Receiving any treatment that has an effect on bone marrow, Taking any medication that has an effect on bone marrow, An allergy to cobalt or any other medication, vitamin, dye, food or preservativeI understand that certain herbal products, vitamins, minerals, nutritional supplements, prescription and non-prescription medications may result in side effects when they interact with the B12 or Amino Acid Injection.Treatments: Typically every 5-7 days or as determined by providerI understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I further agree in the event of nonpayment, to bear the cost of collection, and/or Court cost and reasonable legal fees, should this be required.By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks. I hereby give consent to perform this and all subsequent B12 and Amino Acid Injections with the above understood. I hereby release the doctor, the person injecting the B12 and Amino Acids, and the facility from liability associated with this procedure. DISCLOSURE AND CONSENT:TO THE PATIENT (AND OTHERS LEGALLY RESPONSIBLE FOR THE PATIENT): You have the right, as a patient, to be informed about your condition and how integrative and alternative medicine may be applied in a treatment plan. This disclosure is intended to provide an opportunity for you to make an informed decision so that you may give or withhold your consent to treatment that may be considered unconventional by physicians trained only in the United States. NOTICE: Refusal to consent to the integrative and alternative procedure(s) shall not affect you right to future care or treatment.
I voluntarily request that Dr. Melissa Pearce, MD and other affiliated health care personnel as she may deem necessary, treat my condition (or the condition of the person for whom I am responsible) as described below).
I understand that some of, or all of the following integrative and alternative treatments are planned for me (or the person for whom I am responsible), and I voluntarily consent and authorize the following: Administration of homeopathic remedies, herbal and nutritional therapies, off label use of pharmaceuticals, injectable vitamins and amino acids.
I understand that no warranty or guarantee has been made regarding results of treatment. I realize that there may be risks and hazards related to the planned integrative treatment, including worsening of present symptoms, development of new symptoms (especially detox reactions) and undesirable interactions between various treatments, both conventional and alternative.
I have been given an opportunity to ask questions about the treatment of this health condition using conventional, integrative, and alternative methods. I have had an opportunity to discuss the possible risks and hazards of treatment and non-treatment and I believe that I have sufficient information to this informed consent. I certify this form has been fully explained to me, that I have read it (or have had it read to me), that the blank spaces have been filled in, and that I understand its contents. I also certify that Dr. Melissa Pearce, MD has provided this Disclosure and Consent Form to me and fully explained the diagnostic and treatment options available and has made no guarantees to me as to the success of this treatment. I acknowledge that Dr. Melissa Pearce, MD or her designated assistants have informed me that she functions only as an educator and consultant, not as the primary care physician for any patient. I have assured her that I have another primary physician and do not/will not rely on Dr. Melissa Pearce, MD for that role.
SIGNATURE OF THE PATIENT OR OTHER LEGALLY RESPONSIBLE PERSON REQUIRED BELOW