Weight Loss Informed Consent

Weight Loss Informed Consent

Informed Consent for Medically Managed Weight Loss Therapy
Name*

First NameLast Name
Home Address (MUST ALSO BE YOUR SHIPPING ADDRESS FOR MEDICATIONS) **Please double check for typos! Our office & the pharmacy is not responsible for shipping issues due to patient error. WE CANNOT PRESCRIBE MEDS TO PATIENTS OUTSIDE OF FLORIDA*

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Date of Birth*

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Program Policies and Procedures
The vast majority of patients are telemedicine. YOU ARE NOT PERMITTED TO BE DRIVING WHILE ENGAGING IN A VISIT. YOUR CALL WILL IMMEDIATELY BE DISCONNECTED AND YOU WILL BE CHARGED FOR THE VISIT. Safety is first and we do not want to be responsible for any potential accidents.*

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I have double checked the above entered home/shipping address and it is correct.*

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I understand that the Weight Loss Therapy is to treat your primary care diagnosis of being overweight or obesity to improve your primary health and co-morbidities.*

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Dosing errors CAN happen; especially with compounded medications. It is IMPERITIVE that you read the instructions on your vial. The dose in mg is what is important; units are based on concentration. For example, 50 units literally can be 2.5mg or 15mg based on the concentration of the medication. Units, ML and MG are not the same thing. READ INSTRUCTIONS. Contact our office or pharmacy with questions you may have prior to injecting to ensure there are no errors.*

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The Initial Visit is $125 (non-refundable and non-transferable) and that is to establish yourself with the practice for the weight loss program. The Initial Visit includes a review of your medical history, goals and lab work will be ordered. If you have acceptable lab work that is dated within 90 days, we are able to accept that. If you are being prescribed a stimulant (phentermine, Adipex, Qysmia), a recent EKG must be on file. If you are ready to start the program and order your meds on this visit, we can do that as well! If you're not ready, you can schedule at anytime to get started!*

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Our office uses the patient portal to communicate with patients. Please ensure you have activated your patient portal through CHARM. Our scheduling platform, Schedulicity is where you will self-schedule and self-manage all your appointments. Please be sure you are subscribed to receive our newsletters and don't forget to join our PRIVATE Facebook Group for updates, information, sales and more. Text messages are not the best way to communicate with our office for any medical advice or HIPAA protected information; you will be asked to use your patient portal.*

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Starting the program: You will receive a Welcome Message in your patient portal that includes customized dietary macros and other information once you have officially started the program. Once you have selected the medication and it has been ordered or prescribed, you will officially begin our weight loss program. If your medication is compounded, the medication will be shipped directly to your home within the current turn-times of the compounding pharmacy. Please be sure to update us with any address changes. Your initial payment for the first month of the program is due at this visit and before prescriptions are sent. The payment depends on which medication option has been prescribed (see below).*

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Prescription medication will only be prescribed as a 30-day supply and only during your monthly appointments (renewal appointments). After 3 months, you are able to switch to a 3 month plan, if you desire. Please be sure to schedule your appointments on time as we will not refill meds outside of appointments. At each monthly visit, your renewal payment will be due. If you wish to stop the program at any time, simply cancel your next appointment (renewal) with at least a 48-hour notice to avoid the cancellation fee. Please keep in mind that many weight loss medications cannot be stopped abruptly and require a wean-down. Please consider this when scheduling, rescheduling or cancelling appointments. If you decide to stop the program mid-month, no refunds, credits or returns for medications are permitted. If you do not cancel your appointment with a 48-hour notice, you will be charged the cancellation fee. If you wish to keep your appointment but then decide not to renew the weight loss program and/or order medication, you will be charged the normal office visit fee ($125) to see the provider. We are also not able to post-date payments. All renewal payments are due in full at the time of your appointment. If payment is unable to be made, you may incur a late fee and your meds will not be ordered. Please schedule accordingly.*

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WEIGHT LOSS PRICING

The cost of the program is per month and depends on the medication.

All fees are transparent and available on our website at https://dawsonmedicalcenter.com/weight-loss-program

Special notes about brand name medications & insurance coverage (prior auths)

*ALWAYS check to see if your insurance covers these medications. Many plans have GLPs completely excluded and will not even accept a prior authorization request. If your policy does cover these medications and it requires a prior authorization, we will attempt to process a prior authorization through your insurance. There is a $50 NON-REFUNDABLE fee for our office to do so due to the time and resources it takes to obtain these prior authorizations. This fee is charged each time your insurance requires a prior authorization (while most insurance companies require only 1 per year, so much with these medications are changing, we have seen them require authorizations every 3 months). Please note that there is NO GUARANTEE of approval. In the event of denial, the $50 prior authorization fee is non-refundable.

Another note about brand name medications through non-compounding pharmacies: we cannot guarantee availability of medications in stock. Most of the GLPs are on backorder with "no end date available."

If your insurance denies coverage, if the pharmacy is out of stock or if you do not have insurance, please select the compounded programs!
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Please read the Welcome Message in your patient portal after your first medication appointment. It contains important information and instructions to get started.*

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Compounded medication orders are placed once a week on Friday; regardless of the day of your appointment. Ordering in bulk is how we have been given such affordable pricing. The turn around time starts when the order is placed (not from your appointment).*

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BRAND OZEMPIC, WEGOVY, MOUNJARO: You understand that it is YOUR responsibility to seek prior authorization from your insurance company if you wish to be prescribed Brand Ozempic, Wegovy or Mounjaro. You further understand that there are no guarantees of approval from the insurance company and that any fees are non-refundable. You understand that the pharmacy of your choice may be out of stock of the medication and that is out of the control of Dawson Integrative Medical Center, LLC. You understand that If Dawson Integrative Medical Center, LLC must get involved in the prior authorization process, there is a $50 fee per prior authorization, that approval is not guaranteed and that the fee is prepaid and non-refundable. You understand that you must meet the criteria of your insurance company to be considered; however, there is no guarantee of approval. You understand that the pharmacy may elect to deny your purchase of brand medication without a proper diagnosis, despite insurance approval. You understand that prior authorizations may take several weeks to be processed by insurance. You understand that Dawson Integrative Medical Center, LLC will not perform any appeals on your behalf and it is solely your responsibility.*

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Each monthly visit is your renewal appointment. The monthly amount will be charged at this visit to renew the program for that current month. If you do not renew the program but still keep the appointment, your visit will be converted to a regular office visit and charged for only that. Services must be paid at the time of service with your credit card on file. It is your responsibility to update the card on your profile prior to your appointments. If you wish to discontinue the program, simply cancel your appointment with at least a 48 hour notice. If you opt to prepay and preorder for any medication OR elect the 3 month option, there are NO refunds available.*

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It is the sole responsibility of the patient to update the shipping address as Dawson Integrative Medical Center, LLC will not be responsible for missed or incorrect delivery.*

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If you are late for your appointment, do not cancel with a 48 hour notice or no-show, you will be charged the $100 fee.*

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If you are ordering a compounded medication; such as semaglutide and tirzepatide, please understand that there are nationwide shortages and compounding pharmacies can be backlogged at times. This is a nationwide issue and all REPUTABLE pharmacies are being impacted with demand. The normal turn time is about 5 business days; however, during high volume, please expect turn times to typically be 10-14 business days from your appointment. There are times that this time frame is much better, but we believe in transparency and set realistic expectations for our patients. There are no rushes.*

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Health insurance may not cover services provided at Dawson Integrative Medical Center, LLC. If you wish to seek insurance reimbursement, we would be happy to provide you itemized invoices that you can submit to your insurance company.*

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Phentermine is a controlled substance medication. You agree that you will take your medications as prescribed. You agree to follow your medical providers' instructions. You agree that you will not sell or share your prescriptions to other individuals.*

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I understand that treatments used at Dawson Integrative Medical Center, LLC might not be considered a medical necessity. Treatments rendered are for the purpose of improving your quality of life through hormone restoration, nutritional supplemental counseling and weight loss treatment. Treatments may improve your primary health.*

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You agree that if you are having any side effects or being sick, that you will follow up with your care provider or go to an urgent care or emergency room.*

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You acknowledge that Dawson Integrative Medical Center, LLC are not your primary care provider unless you have elected so. You agree that you will continue with routine care through your primary care provider and notify them of treatments prescribed at Dawson Integrative Medical Center, LLC or elect the group as your primary care provider.*

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You understand that there are no refunds for services or products. We cannot accept medications for any type of refund or credit. Pharmacies will not accept any medications returned. All sales are final.*

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You understand that having an appointment with Dawson Integrative Medical Center, LLC does not necessarily entitle you to being issued a prescription for weight loss medication or additional medications. Every individual is different and it is at the medical provider's discretion to issue a prescription.*

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You understand that you must maintain your follow up appointments to remain on treatment. It is important that lab work is monitored regularly for safety purposes. It is important that Dawson Integrative Medical Center, LLC manages your treatment and it is at our discretion to provider recommendations, changes in courses of treatments and laboratory orders at regular intervals.*

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You acknowledge that you have been advised of the risks and benefits of treatment. You also acknowledge that you have been advised of possible complications and side effects. You understand the risks, benefits, complications and side effects of treatment.*

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You are voluntarily requesting treatment with Dawson Integrative Medical Center, LLC regarding weight loss therapy, for primary care diagnosis, as determined by a mutual decision between yourself and the medical provider; even if your hormone levels are considered to be in normal range for my age based off other medical society recommendations and guidelines; or if you are considered overweight and not obese.*

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You do not and will not hold any medical practitioner of Dawson Integrative Medical Center, LLC responsible for performing age-related preventative care. You agree that you will follow up with your primary care provider to obtain screenings and you hold Dawson Integrative Medical Center, LLC harmless of an adverse event occurs during your treatment. You will ensure that your primary care provider provides the results of such screenings to Dawson Integrative Medical Center, LLC as this could change the treatment prescribed to you.*

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You understand some medications are from FDA compounding pharmacies but that the compounded medications may not be FDA approved for specific reasons we are prescribing them (commonly know as "off label). Compounding pharmacies have rigorous inspections, must meet compliance and have regulations that must be followed.*

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Cardiovascular (heart or blood pressure): These problems may include heart palpitations, irregularbeats, or rapid heartbeat. These effects are usually mild but can result in serious problems includingheart attack or stroke. Also, these medications may increase blood pressure, which if left untreated can lead to heart attack or stroke. If you discontinue the weight loss medication, the elevated blood pressure usually resolves. For this reason, if you are on blood pressure medications you are required to monitor your blood pressure daily and discontinue medications if blood pressure rise, your heart rate increases, or you feel palpitations. This is most common on stimulant appetite suppresants.

Sudden Death: Patients with morbid obesity, particularly those with hypertension, heart disease, ordiabetes, have a statistically higher chance of suffering sudden death when compared to normal weight
people without such medical problems. Rare instances of sudden death have occurred while obese patients were undergoing medically supervised weight reduction, though no cause-and-effect relationship
with the diet has been established. The possibility cannot be excluded that some undefined or unknown factor in the treatment program could increase this risk in an already medically vulnerable patient.

Reduced Potassium Levels: The calorie level you will be consuming is NOT low calorie and it is important that you consume the calories which have been prescribed in your diet to minimize side effects. Failure to consume all of the food and fluids, nutritional supplements or taking a diuretic medication (water pill) may cause low blood potassium levels or deficiencies in other nutrients. Low potassium levels can cause serious heart irregularities. When someone has been on a reduced calorie diet, a rapid increase in calorie intake, especially overeating or binge-eating, can be associated with bloating, fluid retention, disturbances in electrolytes, or gallbladder attacks and abdominal pain. For these reasons, following the diet carefull y and following the gradual increase in calories after weight loss is essential.

Gall Bladder Disease: Any program resulting in rapid weight loss may precipitate the formation of gallstones, which could lead to cholecystitis (inflammation of your gallbladder), which is a medical urgency or emergency and could require surgery. This is typically because of the rapid weight loss, not the medications you are taking. Symptoms include right upper abdominal pain, abdominal just below your ribs, nausea, and vomiting.

Pancreatitis: Pancreatitis, or an infection in the bile ducts, may be caused by gallstones or the development of sludge or obstruction in the bile ducts. The symptoms of pancreatitis include pain in the left upper abdominal area, nausea, and fever. Pancreatitis may be precipitated by binge-eating or consuming a large meal after a period of dieting. Also associated with pancreatitis is long-term abuse of alcohol and the use of certain medications and increased age. Pancreatitis may require surgery and may be associated with more serious compliactions and dealth.

Psychiatric: There are reported cases of “hysterical or psychotic reactions” associated with the use or discontinuation of some of the drugs utilized for weight loss purposes. These reactions are extremely
rare.

General:

Men over 40 and post-menopausal women in general, and patients with risk factors for cardiovascular disease should have a cardiovascular evaluation before entering a medically managed weight loss
program. This may include an ECG, a stress test, or other testing procedures, as per the discretion of a cardiologist. If you are over the age of 40, post-menopausal (female), smoke, have a history of high blood pressure, high cholesterol or you are diabetic, you acknowledge that you have had a cardiac evaluation and that you have been cleared medically prior to starting this weight loss program.

Common, but troublesome side effects may include but not be limited to dry mouth, palpitations, “speedy” feeling, headaches, sleeplessness., Rash, fever, nausea, vomiting, allergic reactions, decreased insulin
sensitivity, flushing, headache, fatigue, lightheadedness, abdominal cramping, joint pain, fluid retention, and additional side effects not listed that will be discussed during your evaluation with Dawson Integrative
Medical Center, LLC. These side effects are generally rare, and most patients tolerate treatment without an issue.

Drug interactions may occur if other medications are taken. Therefore, I will check with my prescribing medical provider before starting the program if I am taking other medications.

Certain medical conditions may be worsened if on this program, including glaucoma, hypertension, and heart disease.

Pregnancy (Females Only). If you become pregnant, inform your physician immediately. Your diet must be changed promptly to avoid further weight loss because a restricted diet could be damaging for a
developing fetus. You must take precautions to avoid becoming pregnant during the course of weight loss.

The use of medications for weight management is indicated for those patients who have a BMI of 30 or higher or a BMI of 27 or higher with other medical conditions such as high blood pressure, diabetes, or
high cholesterol. Prescribing medications for patients not fitting these criteria, is considered “off label” and not “FDA approved.” Therefore, the potential risks vs. benefits may be great. For patients not fitting the
BMI criteria for use of appetite suppression medication, you are acknowledging that:

1. You have put forth a true effort to lose weight through diet and exercise over the past 6 months and have still not achieved your weight loss goals.
2. That your inability to lose weight is causing significant emotional distress.
3. You are choosing to enter this medically managed weight loss program voluntary and hold harmless Dawson Integrative Medical Center, LLC for use of such medications.

You acknowledge that alcohol and illicit drug use is prohibited in the program. Drugs like cocaine andamphetamines when used in conjunction with appetite suppressants and other medications prescribed could cause serious injury or death. The use of alcohol will also affect your results.

You understand that the physician and you will determine what my daily caloric intake will be at my initial visit.

You acknowledge that you understand that the amount of weight loss varies from patient to patient, and is, to a large extent, dependent on each patient’s personal motivation and commitment to their diet and exercise plan. No claims as to efficacy or specific amount of weight loss is either expressed or implied. You understand the importance of routinely following up with Dawson Integrative Medical Center, LLC to
monitor your progress during treatment. You understand this is vital to the safety of the treatment program and certify that you will be returning monthly as prescribed.

You hereby authorize Dawson Integrative Medical Center, LLC and additional staff of Dawson Integrative Medical Center, LLC to evaluate you for admission into Dawson Integrative Medical Center, LLC weight
management program and treat you accordingly. You consent to obtaining blood work before treatment if deemed necessary. You certify that you am signing this under your free will and am competent to make your own medical decisions.

You have reviewed the mentioned risks and have determined the benefits outeigh the possible risks associated with medically managed weight loss therapy with Dawson Integrative Medical Center, LLC. You
release any claim in court or any type of complaint that could result from treatment with Dawson Integrative Medical Center, LLC and any other staff associated with Dawson Integrative Medical Center, LLC and will not hold liable any provider or staff of Dawson Integrative Medical Center, LLC.

You understand that treatment modalities utilized by Dawson Integrative Medical Center, LLC might not be supported by scientific/medical literature and could be seen as experimental or based off anecdotal
claims. Many medical providers, including endocrinologists, surgeons, family practice doctors, etc., might see these types of treatments as not medically necessary. You also understand that many of the medications
being utilized within Dawson Integrative Medical Center, LLC medically managed weight loss program are used “off label” and might not be FDA approved for weight loss purposes.

Risks and Benefits Acknowledgement

You recognize the potential risks of this treatment program, and you also understand the potential benefits of weight loss, which may include:

1. Decreased risk of heart attack.
2. Decreased risk of adult-onset diabetes mellitus.
3. Decrease risk to developing arthritis or developing musculoskeletal conditions that are caused by excessive weight.
4. Increased emotional and psychological well-being.
5. Decreased risk of developing certain types of cancer.

You acknowledge that the medically managed weight loss program to improve primary health recommended to you by Dawson Integrative Medical Center, LLC is just one of multiple strategies to reduce weight.

Alternative treatment options include:

1. Diet and exercise alone without medications.
2. The use of other kinds of medications to achieve appetite suppression.
3. Non-medical weight loss programs like Weight Watchers.
4. Bariatric Surgery.

Any questions you have regarding this treatment have been answered to your satisfaction. You understand that you will be responsible for administering the medications prescribed to you if I do not have them administered to you in clinic. You also promise to comply with the dosages and frequency of medications prescribed to you.

You certify that you are under the regular care of a primary care provider for any other conditions you might have or am found to have. You will consult with your primary care provider or specialist regarding any other condition you might have. You understand that if you do not have a primary care provider, that you will be encouraged to seek
one out. You acknowledge that you are seeking care at Dawson Integrative Medical Center, LLC for medically managed weight loss services Dawson Integrative Medical Center, LLC offers. You acknowledge you are not wanting to establish primary care with Dawson Integrative Medical Center, LLC and you are here for specialized care including weight loss therapy, diet counseling, exercising counseling, (additional services you have) etc.

Regaining Weight Acknowledgement:

There is a Risk of Regaining the Weight you have lost... Obesity is a chronic condition, and the majority of overweight individuals who lose weight have a tendency to regain all or some of it back over time. Factors which favor maintaining weight loss include exercise, adherence to a calorie that is low-calorie, nutritious, and full of lean proteins and vegetables, and planning a strategy for coping with weight regain before it occurs. Successful treatment may take months or even years. Utilizing medications to assist you in your weight loss goals in addition to diet and exercise could result in the weight coming back if you do not
maintain eating a healthy diet and exercising. Additionally, if you have had fluctuations in your weight in the past, it may be more difficult to maintain the weight you lose.

You certify that you have read the above consent and fully understand it. You believe that you have adequate knowledge upon which to base this weight loss informed consent. You fully understand what you are signing and hereby request and consent to weight loss treatment. You have read, understand, and agree to all the above statements.
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Florida Statutes 501.0575 Weight Loss Consumer Bill of Rights.

(1) The Weight-Loss Consumer Bill of Rights shall consist of the following provisions:

(A) WARNING: Rapid weight loss may cause serious health problems. Rapid weight loss is a weight loss of more than 1.5-2 pounds to 2 pounds per week or weight loss of more than 1% of body weight per week after the second week of participation in a weight-loss program.

(B) Consult your personal physician before starting any weight-loss program.

(C) Only permanent lifestyle changes, such as making healthful food choices and increasing physical activity, promote long0term weight loss.

(D) Qualifications of this provider are available upon request.

(E) You have a right to:

1. Ask questions about the potential health risks of this program and its nutritional content, psychological support, and education components.

2. Receive an itemized statement of the actual or estimated price of the weight-loss program, including extra products, services, supplements, examinations and laboratory tests.

3. Know the actual or estimated duration of the program.

4. KNow the name, address and qualifications of the dietitian or nutritionist who has reviewed and approved the weight-loss program according to s.468.505(1)(j), Florida Statutes.

(2) The copies of the Weight-Loss Consumer Bill of Rights to be posted according to s.501.0573(6) shall be printe in at least 24-point boldfaced type on one side of a sign. The palm-sized copies to be distributed according to s.501.0573(5) shall be in boldfaced type and legible. Each weight-loss provider shall be responsible for producing and printing appropriate copies of the Weight-Loss Consumer Bill of Rights.
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Weight Loss Informed Consent

Program Policies and Procedures