• Phentermine Weight Loss Program Consent Form

  • Phentermine is an appetite suppressant that has been taken safely by millions of people, but as with any medication there is a possibility of side effects or an adverse reaction. Common side effects are dry mouth, nervousness, difficulty sleeping, and occasional dull headaches. It can take approximately 4-7 days for your body to adjust to the medication. Less common side effects include heart palpitations, increased blood pressure, and shortness of breatb, swelling of your feet and ankles, exercise intolerance, dizziness, upset stomach, constipation, and itching.

    In case of serious side effects, stop taking the Phentermine and seek immediate medical attention at your local ER. If you are currently taking medication that contains amphetamines such as Adderall or Wellbutrin you must stop taking them for at least 14 days. You must bring a note from your doctor stating that you can safely be off your medicine. While taking Phentermine avoid taking the following: Decongestant medications (Sudafed/Pseudoephedrine, Tylenol Sinus, Claritin D, Zyrtec D and Allegra D), stimulant medications, high doses of caffeine, other weight loss medication, ephedrine, MAO inhibitors and alcohol use. Please consult with the clinic staff prior to starting any new medications. Persons with the following medical conditions can't take Phentermine: Uncontrolled high blood pressure, heart disease, history of heart attack, arteriosclerosis (clogging of the arteries), severe heart murmurs, history of stroke, liver or kidney failure, overactive thyroid, glaucoma, uncontrolled anxiety, depression, those with a history of drug dependency (or addiction prone personalities). Phentermine is NOT to be taken while pregnant or breast feeding. Phentermine needs to be discontinued two weeks prior to surgery where general anesthesia will be used.

    Phentermine should not be crushed or chewed and capsules should never be opened. The tablets can be safely broken in half. No one under the age of 17 will be allowed to participate in Phentermine assisted weight loss. Those under the age of 18 must be accompanied by a parent or guardian on the first visit. No client who has a BMI of less than 27% will be allowed to participate in the Phentermine assisted weight loss and goal weight cannot be below 19%. Clients with a BMI of 27% to 29% may only be on Phentermine if they have diagnosed co-morbidities (hypertension, heart disease).
    Mega Health Services reserve the right to refuse initial or continued treatment to any individual without liability to the clinic.

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  • Patient Information

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  • Medical and Surgical History

  • Social History

  • drinks/week.

  •    packs/day for    years  

  • Type    

  • Caffeine (coffee/soft drinks) amount per day:     

  • Cancer Screening History

    Please provide the dates and results of the most recent testing
  • Colonoscopy:
    Mammogram:      
    Pap smear:       

  • Family Medical History

    Specify current health status or cause of death, age or age at death Medical Problems
  • Father: Alive      . Age at death            

    Reason for death:        

  • Mother: Alive      . Age at death      

    Reason for death:      

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  • B-12 or Lipotropic/B-12 Consent Form

  • I am requesting Vitamin B-12 and or Vitamin B-12 Lipotropic injections. I understand that this injection contains Vitamin B-12, and may contain Lipotropics
    (Choline, Inositol, and Methionine) if I desire.

    I understand that Vitamin B-12 and Vitamin B-12 Lipotropics are amino acid/nutrient/vitamin injections, and, as with all injections, may cause pain, bruising or redness at the site of the injection. I also understand that a diet and exercise regimen is needed in order for the Lipotropics to be successful.

    Just doing the injections will not help me lose weight.

    I certify that everything on this form is true and correct to the best of my knowledge.

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