I request the use of Phentermine along with diet and exercise 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, 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 understand that there is no guarantee for the effectiveness of Phentermine. Prior to 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, etc), emphysema, asthma, palpitations, glaucoma, overactive thyroid, anxiety/nervousness, and any history of stroke or cancer. These contraindications have been fully discussed with me. If fail to disclose any medical condition that Ihave, I release T. Garrett Family Health and Wellness Clinic and Travicia Garrett, NP from any liability associated with this treatment. Initials: What important information should I know about Phentermine? Weight loss during pregnancy can harm an unborn baby, even if you are overweight. DO NOT USE Phentermine if you are pregnant or think that you may be pregnant. Do not breastfeed while taking phentermine Do not take Phentermine ff you have taken certain drugs used for low mood (depression) like isocarboxazid, phenelzine, or tranylcypromine or drugs used for Parkinson's disease like selegiline or rasagiline in the last 14 days. Taking this drug within 14 days of those drugs can cause very bad high blood pressure. If you are taking any of these drugs: Fluoxetine, fluvoxamine, paroxetine, or sertraline.
Do not take Phentermine together with other diet medications (prescription, over the counter, or natural
Phentermine may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be alert.
Drinking alcohol can increase certain side effects of this medicine.
Phentermine may be habit forming and should be used only by the person it was prescribed for. Never share phentermine with another person, especially someone with a history of drug abuse or addiction.
Do not stop using Phentermine suddenly, or you could have unpleasant withdrawal symptoms. Ask your healthcare provider how to avoid withdrawal symptoms when you stop this medicine.
Fax: 214-580-5180 www.tgarrettclinic.com