T.Garrett

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

Phentermine is a stimulant. Phentermine is an appetite suppressant that affects the central nervous

Phentermine is used to treat obesity

What are some things you should know:

You should not take phentermine if you are allergic to it or if you have a history of heart disease (coronary artery disease, heart rhythm problems, congestive heart failure, pulmonary hypertension) Severe or uncontrolled blood pressure

You are in an agitated state If you are allergic to other diet pills, amphetamines, stimulants, or cold medications. Phentermine can harm an unborn baby. Phentermine can pass in the breast milk and may harm a nursing baby. Do not breast feed while taking Phentermine. Tell all of your health care providers that you take this drug. This includes your doctors, nurses, pharmacists, and dentists. Avoid driving and doing other tasks or actions that call for you to be alert until you see how this drug affects you. People who take drugs for weight loss like this drug may have a higher chance of having raised pressure in the lungs. This is rare but is often deadly. Talk with your doctor. Do not take this drug for longer than you were told by your doctor. If you have been taking this drug for a long time or at high doses, it may not work as well and you may need higher doses to get the same effect. This is known as tolerance. Call your doctor if this drug stops working well. Do not take more than ordered. If you have been taking this drug for many weeks, talk with your doctor before stopping. You may want to slowly stop this drug. This drug may be habit-forming; avoid long-term use. Tell your doctor if you have a history of drug or alcohol abuse. This drug may cause unsafe heart-related side effects. Tell your doctor if you have any heart disease.

Check blood pressure and heart rate as the doctor has told you. Talk with the doctor. If you have high blood sugar (diabetes), talk with your doctor. Follow the diet and workout plan that your doctor told you about. Talk with your doctor before you drink alcohol.

Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect:

Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.

Fax: 214-580-5180 www.tgarrettclinic.com

Signs of high blood pressure like very bad headache or dizziness, passing out, or change in eyesight. Change in how you act. Chest pain or pressure or a fast heartbeat. A heartbeat that does not feel normal.

Swelling on legs or feet. All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away: Dizziness.

Feeling nervous and excitable. Headache.

Hard stools (constipation Loose stools (diarrhea Dry mouth.

How is the medication best taken?

Take this medication early in the day to prevent sleep problems Take before or after breakfast.

What do I do if I miss a dose?

Take a missed dose as soon as you think about it. If it is close to the time for your next dose, skip the missed dose and go back to your normal time. Do not take 2 doses at the same time or extra doses.

Store at room temperature. Store in a dry place. Do not store in a bathroom. Keep all drugs in a safe place. Keep all drugs out of the reach of children and pets. Check with your pharmacist about how to throw out unused drugs.

I understand that use of Phentermine is absolutely contraindicated during pregnancy and breast feeding. Initials:

I understand that it is my responsibility to inform T. Garrett Family Health and Wellness Clinic and their medical providers if I am pregnant, trying to become pregnant, or if I become pregnant during the course of the weight loss treatment/program. Initials:

I agree to immediately report any problems that might occur to my health care provider during the weight treatment/program. I further understand that not complying with the dosage recommendations, diet and exercise recommendations could increase risks and alter my results of the weight loss program. If do not follow these recommendations and restrictions, I agree to release T. Garrett Family Health and Wellness Clinic and their healthcare providers from any liability arising as a result of this. Initials:

I understand that I may quit the program at any time. While adverse side effects or complications are not expected, in the event that I experience an illness, adverse reaction, or complication I understand that I need to contact T. Garrett Family Health and Wellness Clinic and their health care provider immediately. 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 of there are any changes in my medications or any other changes relevant to this weight loss program/treatment, I will informT. Garrett Family Health and Wellness Clinic and their health care provider at that time. Initials:

I have read and fully understand the above terms. All my questions have been addressed to my satisfaction. I agree to release Travicia Garrett, NP and T. Garrett Family Health and Wellness Clinic and their staff from any liability associated with this treatment.