New Weight Loss Packet

Permission for Treatment

The undersigned, hereby voluntarily consent to medical care, diagnostic treatment, and/or minor surgical treatment deemed advisable and necessary in the diagnosis and treatment of my condition by any of the doctors and/or employees of Padgett Medical Center, LLC at any of their locations. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as a result of treatment or examination in the office.

Advanced Directives 

All adults in health care settings have the right in the state of Florida to an “advanced directive”. This is a written or oral statement, made and witnessed in advance of a serious injury or illness, stating how medical decisions will be made. An advanced directive enables you to state your choice, or name someone to make your choice for you, should you become unable to make decisions about your medical care. A copy of the advance directive law is available upon request

 

I have read the above and received further information if requested on advance directives.

 

Financial Policy 

I authorize payment of medical benefits directly to Padgett Medical Center for professional services provided. I understand that I am financially responsible for all charges for services provided to me by Padgett Medical Center, including all remaining balances.

In order to ensure proper care, the doctor(s) at Padgett Medical Center may have need to consult with other physicians currently treating you. Please fill out the following information about your current doctors. If you need additional space, see the receptionist for more paper.

             I understand that by filling out the following information, I am agreeing to allow Padgett Medical Center to discuss my treatment with the doctors/facilities listed below.

             I understand that this list does not preclude Padgett Medical Center from requesting records from doctors/facilities not listed below, in the future.

             I understand that it is my responsibility to inform Padgett Medical Center if I begin care under a new doctor/facility.

             I understand that it is my responsibility to inform Padgett Medical Center anytime I visit a quick care, urgent care, emergency room, or hospital.

Patient Rights and Responsibilities 

Welcome to Padgett Medical Center. Our goal is to provide quality health care to persons in this community. As a patient, you have rights and responsibilities. The clinic also has rights and responsibilities. We want you to understand these rights and responsibilities so you can help us to provide health care for you. Please read this statement and inform us if you have any questions.

 

Human rights

·      You have the right to be treated with respect and dignity regardless of race, religion, sex, or national origin.

 

Payment for services

·      You are responsible for all payments at time of visit. Please ask an associtate

 

Privacy

·      You have the right to have interviews, examinations, and treatment in privacy. Your medical records are also private. Only legally authorized persons will have access to your records.

 

Health care

·      You are responsible for providing us accurate, complete, and current information about your health so that we can provide you proper treatment. You have a right and are encouraged to participate in decisions regarding your treatment.

·      You have the right to information and explanations in the language you normally speak and in words you understand. You have a right to information about your health or illness, treatment plan (including risks), and expected outcome, if known. If you do not wish to receive this information, or if it is not medically advisable to share that information with you, we will provide it to legally authorized persons.

·      If you are an adult, you have the right to refuse treatment to the extent permitted by law, and to be informed of the risks of refusing. You are responsible for the outcome of refusing treatment.

·      You have the right to health care and treatment that is reasonable for your condition and within our capacity. You have a right to be transferred or referred to another facility for services that we cannot provide. However, we (Padgett Medical Center) are not financially liable for any additional costs incurred.

·      You have a right to the appropriate assessment and management of your weight within the available resources of the clinic.

 

Clinic rules

·      You have the right to receive a copy of your patient information, health services we provide, personal conduct polices, and the use of our property and resources. You are responsible for obeying these rules.

·      You are responsible for appropriate use of our services, which include following our staff’s instructions, and making and keeping scheduled appointments.

·      If you do not change your appointment a minimum of 24 hours in advance, you will be charged a $25 fee. This will hold true for every time you change an appointment.

·      If you are more than 15 minutes late for your appointment, you will be charged a $25 fee that same day.

·      If we have not heard from you by 30 minutes past your scheduled appointment time, you will be considered a no show and lose your slot.

·      You are responsible for the supervision of children you bring into the clinic. You are responsible for their safety, as well as the protection of others and our property.

·      You may not smoke or loiter on the property. This includes the entire professional plaza.

·      In an effort to be in good standing with our neighbors and the landlord, we ask you refrain from having anyone, family, friend, pets, etc., waiting in a car while you are here. You may bring one (1) additional person inside with you as you wait for your appointment. Please ask anyone else to come back after the appointment is over.

·      Inappropriate conduct by the patient or anyone accompanying the patient will not be tolerated. Profanity, disorderly conduct, threats of violence, or acts of violence will result in the discharge of the patient from our facility. You, as the patient, are responsible for the actions of your guests.

·      Please bring everything requested by the doctor and staff to your appointment. Failure to have any paperwork requested may result in a delay of your seeing the doctor and/or receiving your prescriptions.

·      Presenting a forged document (prescription history, MRI, EKG, etc.) or altering a prescription written by the physician will result in discharge from the practice.

·      Proper dress code is required. Please refrain from wearing tank tops, sleeveless shirts, or clothing with profanity. Casual dress is requested.

 

Hours of operation:

·      Monday through Friday 9am – 5pm, except on major holidays.

·      For after-hours emergencies, please go to the nearest emergency room.

·      We do not accept walk-in patients. To schedule an appointment, please call that specific facility.

            Ocala – (352) 369-0104                      Tampa – (813) 888-7710

 

Medical records

·      Any request for copies of medical records takes 24 hours minimum. There is a charge for copies of your record ($1 per page for the first 25 pages, $0.25 per page for pages 26 and after). Please ask a staff member for a page count prior to requesting the full record be copied.

Any request for billing statements take a minimum of one (1) week. The doctor has to review any statement before it is sent out. Please allow appropriate time when asking for this service. If records need to be sent with the statement, see above.

Notice of Privacy Practices 

This notice describes how medical/protected health information may be used and disclosed and how you can get access to this information. Please review carefully.

 

SUMMARY:

            By law, we are required to provide you with our Notice of Privacy Practices (NPP). This Notice describes how your medical information may be used and disclosed by us. It also tells you how you can obtain access to this information.

 

As a patient, you have the following rights:

The right to inspect and copy your information
The right to request corrections to your information
The right to request that your information be restricted
The right to confidential communications
The right to report a disclosure of your information
The right to a paper copy of this form
 

            We want to assure you that your medical/protected health information is secure with us. If you have any questions regarding this form, please contact one of the office staff at Padgett.

 

            I hereby acknowledge that I have read this copy of NOTICE OF PRIVIACY PRACTICES. I understand that if I have a question or complaint regarding my privacy rights, I may contact a member of the staff at Padgett Medical Center. I further understand the practice will offer me updates to the NOTICE OF PRIVACY PRACTICES should it be amended, modified, or changed in any way.

 

HIPPA Privacy Practices

HIPAA (Health Insurance Portability and Accountability Act) Information Release & Disclosure Notice

            This notice describes how health information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.

Purpose

            Padgett Medical Center, LLC and its faculty, employees, and non-employees follow the privacy practices described in this Notice. Padgett Medical Center maintains your health information in records that are kept in confidential manner, as required by law. Padgett Medical Center must use and disclose or share your health information as necessary for treatment, payment, and health care operations to provide you with quality health care.

Use and Release of Your Health Information for Treatment, Payment, and Health Care Operations

            Padgett Medical Center has to use and release some of your health information to conduct its business. We are permitted to use and release health information without authorization from you. Treatment includes sharing information among health care providers involved in your care. For example, your health care provider may share information about your condition with radiologists or other consultants to make a diagnosis. Padgett Medical Center may use your health information as required by your insurer to determine eligibility or to obtain payment for your treatment. In addition, Padgett Medical Center may use and disclose your health information to improve the quality of care, and for education and training purposes of Padgett Medical Center residents, and faculty.

How will Padgett Medical Center Use and Disclose My Health Information?

            Your health information may be used for the following purposes unless you ask for restrictions on a specific use or disclosure. Note: You have the opportunity to refuse some of these communications about your health information. The optional items are indicated by (*). Please let a staff member know if you wish to refuse any or all of the optional communications.

·      (*) Padgett Medical Center directories, which may include your name, general condition, and your location in Padgett Medical Center.

·      (*) Family members or close friends involved in your care or payment for treatment.

·      (*) Disaster relief agency if you are involved in your care or payment for treatment.

·      (*) To inform you of treatment alternatives or benefits or services related to your health.

·      Appointment reminders.

·      Public health activities, including disease prevention, injury or disability; reporting births and deaths; reporting reactions to medications or product problems; notification of recalls; infectious disease control; notifying government authorities of suspected abuse, neglect, or domestic violence.

·      Health oversight activities, such as audits, inspections, investigations, and licensure.

·      Law enforcement, as required by federal, state, or local law.

·      Lawsuit and disputes, in response to a court or administrative order, subpoena, discovery request or other lawful request.

·      Coroners, medical examiners, and funeral directors.

·      To prevent a serious threat to health or safety.

·      To military command authorities if you are a member of the armed forces or a member of a foreign military authority.

·      National security and intelligence activities to authorized persons to conduct special investigations.

·      Workers’ Compensation. Your medical information regarding benefits for work-related injuries and illnesses may be released as appropriate.

·      To carry out health care treatment, payment, and operations functions through business associates, such as to install a new computer system.

Your Authorization Is Required for Other Disclosures.

            Except as described above, we will not use or disclose your medical information, unless you allow Padgett Medical Center in writing to do so. You may withdraw or revoke your permission, which will be effective only after the date of your written withdrawal.

            Alcohol and drug abuse information has special privacy protections. Padgett Medical Center will not disclose any information identifying an individual as being a patient or provide any health information relating to the patient’s substance abuse treatment unless the patient authorizes in writing; to carry out treatment, payment, and operations; or, as required by law.

You Have Rights regarding Your Health Information.

            You have following rights regarding your medical information, if requested on the form(s) provided by Padgett Medical Center:

·      Right to request restriction. You may request limitations on your health information that we use or disclose for health care treatment, payment, or operations, although we are not required to comply with your request. For example, you may ask us not to disclose that you have had a particular procedure. We will release the information if necessary for emergency treatment. We will notify you in writing whether we honor your request or not.

·      Right to confidential communications. You may request communications of your health information in a certain way or at a certain location, but you must tell us how or where you wish to be contacted.

·      Right to accounting of disclosures. You must request a list of the disclosures of your health information that have been made to persons or entities for disclosures unrelated to health care treatment, payment, or operations within the past six (6) years for paper health records, and for electronic health records you may request three(3) years, including disclosures for treatment, payment, or operations. After the first request, there may be a charge.

·      Right to a Copy of This Notice. You may request a paper copy of this Notice at any time, even if you have been provided with an electronic copy. You may obtain an electronic copy of this Notice in our office.

Requirements Regarding This Notice.

            Padgett Medical Center is required by law to provide you with this Notice. We will comply with this Notice for as long as it is in effect. Padgett Medical Center may change this Notice and these changes will be effective for health information we have about you as well as any information we receive in the future. Each time you register at Padgett Medical Center for health services, you may receive a copy of the Notice in effect at that time.

Complaints

            If you believe your privacy rights have been violated, you may file a complaint with:

            Office of Civil Rights

            U.S. Dept. of Health and Human Services

            200 Independence Avenue, S.W.

            Washington, DC 20201

Contact Padgett Medical Center at (352) 369-0104 or (813) 888-7710 if:

·      You have any questions about this Notice;

·      You wish to request restrictions on uses and disclosures for health care treatment, payment, or operations; or

You wish to obtain a form to exercise your individual rights.

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.

PHENTERMINE INFORMED CONSENT CONT.

 

            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.

Informed Consent for Injections

 

This document is intended to serve as confirmation of informed consent for injections ordered by the physician at Padgett Medical Center.

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

             I have informed the physician of any known allergies to drugs or other substances, or of any past reactions to any medications or other substances.

             I have informed the doctor of all current medications and supplements I am taking at this time.

             I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits, except in any emergency situation.

             I understand that:

1. The procedure involves inserting a needle into various areas of the body and injecting the medication prescribed to me by the physician at Padgett Medical Center.

2. Risks of injection therapies include but are not limited to:

·  Occasional discomfort, bruising, and inflammation at the site of the injection.

·  Dizziness or light-head feeling after the injections.

·  Fainting or loss of consciousness during the procedure.

·  Allergic reaction to the medication being administered.

             I am aware that other unforeseeable complications could occur. I do not expect the physician to anticipate and or explain all risk and possible complications. I rely on the physician to exercise judgment during the course of treatment with regards to any procedures.

             I understand the risks and benefits of the procedures and have had the opportunity to have all of my questions answered.

             I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance.

My signature on this form affirms that I have given my consent to injection therapy with any different or further procedures which, in the opinion of my physician, may be indicated or beneficial to me. My signature below confirms that:

            1. I understand the information provided on this form and agree to the foregoing.

      2. The procedure(s) set forth above has been adequately explained to me by my physician.

      3. I have received all the information and explanation I desire concerning the procedure.

      4. I authorize and consent to the performance of the injections/ procedure(s).

Medication Addendum

Due to the nature of our business, any medications dispensed to a patient are unable to be returned. Florida pharmaceutical
guidelines prohibit the reuse of medications dispensed to patients when the medication is compounded or not in the original
manufacturer packing with original seals. It is the patients’ responsibility to ask any questions about the medication to the
physician. In the event that a patient leaves the facility with possession of a medication and then decides not to continue treatment
for any reason, we will not accept the return of medications and we are unable to provide a refund on the purchase. We will make
every attempt to ensure patient satisfaction and to keep our prices affordable we must stand behind this policy.
Instructions: Initial each of the following statements to show you understand and agree with them:
______ I understand that all medication sales are final sale and no refunds will be given.
______ I understand that it is my responsibility to ensure that all my questions are answered by the medical doctor.
______ I understand that if I have additional questions or concerns about my medications, I can contact Padgett Medical
Center for clarification.
______ I understand that if I have a side effect from a medication, it is my responsibility to contact the office immediately.
______ I understand that it is my responsibility to let the physician know all current medications that I am taking.
______ I understand that all physicians have opinions that may differ with regards to treatment for a patient and in the event
my primary or other physician does not agree with Padgett Medical Center’s physician protocols this is not a valid
reason for return of medications.

HCG Consent 

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 Thromboembolismanother potentially lifethreatening 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 area of use
 Migraine Exacerbation
 Ovarian Hyper-stimulation 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.

Peptide/ Vitamin / Nutraceutical /Off-Label Medication Consent Form

I hereby request and consent to examination and subcutaneous and or intramuscular injection of vitamins and peptides as well as treatment with naturopathic care, including various modes of elective vitamins, alternative medicine, and peptide injection therapy.  I understand that I am in full control of my body during the examination and it is my responsibility to inform the healthcare provider of any procedure or treatment that I may not feel comfortable with.  I understand that alternative medicine and therapies used have not been FDA approved.  I understand that the use of peptides in medicine is new and not mainstream medicine.  Peptides and Alternative therapies have not all been proven with studies due to the major advancement in medicine.   

I, as a patient, have a right to be informed about my condition and recommended care. This disclosure is to help me become better informed so I may make the decision to give or withhold my consent to any proposed treatment. I understand that treatment may involve bioidentical hormones replacement, subcutaneous and or intramuscular injection of vitamins minerals and peptides etc.), collecting specimens for laboratory evaluation, including blood draws and/or ordering diagnostic imaging and tests, prescription of certain medications and nutritional supplements, counseling and dietary therapy, homeopathic medicines referred to as “remedies.” I understand the U.S. Food and Drug Administration has not evaluated or approved nutritional, herbal and homeopathic supplements; however, they have been widely used in Europe and the United States for many years.

 I also understand that, as with drugs, nutritional supplements, vitamin injection, bioidentical hormone replacement, herbal and homeopathic remedies may cause some side effects in certain individuals, may interact with certain allopathic medications or lab tests, or show symptoms due to certain pre-existing conditions. I do not expect the provider to be able to anticipate and explain all risks and complications, and I wish to rely on the practitioner to exercise judgment in recommending treatments that the practitioner feels at the time, based on the facts then known, are in my best interest.

Nutraceuticals: Can be vitamin injections, amino acids, or combination therapies.  Widely used in alternative medicine.

Off-Label Use of FDA-Approved Drugs I also understand that hormone replacement, vitamin and amino acid injections and peptide therapy may include the “off-label” use of FDA-approved drugs. “Off-label use” means an FDA-approved drug is used in therapies and treatments for which the drug was not specifically approved. As much as forty-six per cent (46%) of certain classes of prescriptions are for off-label use of FDA-approved drugs.

In addition, I assume full liability for any adverse effect that may result from the non-negligent prescribing of the Peptides, Nutraceuticals, Antioxidants, Hormones, Drugs, or other treatments involved in the therapies and medical care prescribed or recommended by Padgett Medical Center’s Provider and Padgett Medical Center, LLC and I waive release the practice from any and all claims (legal or otherwise), grievances, or damages (monetary or otherwise) arising from my treatment as a patient.

 Alternative Medicine: Alternative medicine is a term that describes medical treatments that are used instead of traditional (mainstream) therapies. Some people also refer to it as “integrative,” or “complementary” medicine. More than half of adults in the United States say they use some form of alternative medicine.  Example: Using High Dose Vitamin C IV for Cancer instead of Chemotherapy.

 Peptides: A molecule consisting of 2 or more amino acids. Peptides are smaller than proteins, which are also chains of amino acids. Molecules small enough to be synthesized from the constituent amino acids are, by convention, called peptides rather than proteins.

 

I agree to the use of alternative medicine, peptides, vitamin injections, and nutraceuticals.  I understand that Padgett Medical Center may prescribe alternative treatments including the above and possibly the use of off-label medications for wellness, treatment of hormonal conditions, and other medical conditions. 

 

I have the right to refuse treatment and notify Padgett Medical Center, LLC if I no longer wish to continue treatment.