1. I {name} (patient), am aware that there are certain risks associated with
being overweight or obese. Among them are tendencies for high blood pressure, diabetes, heart attack, heart disease, arthritis of the joints, hips, knees and feet, and many other diseases. Obesity and overweight also reduce my overall life expectancy. I understand these risks may be modest if I am slightly overweight but that these risks can go up significantly the more overweight I am. I recognize these current risks to my health as unacceptable and wish to treat my weight by enrolling in this program through Prevention Center USA.
I hereby authorize Dr. Lee, and whomever he designates as his medical providers, to provide medical care for me to assist me in my weight reduction efforts, to achieve the goals of weight loss and weight maintenance. I understand that such care may include but is not limited to physical examination, laboratory screening, EKG testing, instruction in behavior modification techniques, nutritional counseling, fitness counseling, vitamin supplementation, and may involve the use of appetite suppressants.
2. I further understand that if appetite suppressants are used, they may be used for durations exceeding those recommended in the product literature, and when indicated, in higher doses than the dose indicated in the appetite suppressant labeling. I have read and understand my medical providers’ statements that follow:
“Medications, including appetite suppressants, have labeling worked out between the makers of the medication and the Food and Drug Administration. This labeling contains, among other things, suggestions for using the medication. The appetite suppressant labeling suggestions are generally based on shorter term studies (up to 12 weeks) using the dosages indicated in the labeling.”
“As medical providers, we have found the appetite suppressants helpful for periods in excess of 12 weeks, and at times in larger doses than those suggested in the labeling. We are not required to use the medication as the labeling suggests, but we do use the labeling as a source of information along with our own experience, the experience of our colleagues, and recent studies. Such usage has not been as systematically studied as that suggested in the labeling and it is possible, as with most other medications, that there could be serious side effects.”
“The more common side effects of the appetite suppressants include nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, psychological problems, medication allergies, high blood pressure, rapid heartbeat and heart irregularities. Less common, but more serious, risks are primary pulmonary hypertension and valvular heart disease, heart attack and stroke. Physical injury can result from such things as increased exercise and activity, and GI side effects, such as constipation, diarrhea, and/or bloating, or development of gallbladder disease, can occur from rapid weight loss. These and other possible risks could, on occasion, be serious or fatal. You must decide if you are willing to accept the risks of side effects, even if they might be serious, for the possible help the appetite suppressants may give you.”
3. If I choose a Semaglutide or Tirzepatide medication program I understand that semaglutide and Tirzepatide are 94% similar to natural human glucagon-like peptide 1 (GLP-1) and therefore acts as a physiological regulator of appetite and thereby reducing food intake by reducing feelings of hunger and increasing feelings of fullness/satiety. For long term success the treatment needs to be combined with lifestyle changes including nutritional, exercise and behavioral habits.
I understand that my use of Semaglutide or Tirzepatide may expose me to the risks of various conditions, including but not necessarily limited to low blood sugar (glucose ≤70 mg/dL), fast heart rate, sweating, shakiness, intense hunger, or confusion, nervousness, overstimulation, restlessness, dizziness, insomnia (inability to sleep), euphoria (sense of well-being), dysphoria (sense of unhappiness or depression), tremor, headache, dry mouth, diarrhea, constipation, other gastrointestinal disturbance, medication allergies, impotence, or changes in libido. I further understand that my use of semaglutide may expose me to the less probable but more serious risk of potential pancreatitis, cholelithiasis and cholecystitis (gallstone and gallbladder disease), thyroid disease, heart rate, and dehydration. I am encouraged to ask questions as concerns may arise. I should promptly bring any questions I have to the attention of a qualified provider.
I understand that if I begin to experience any unusual or unexpected symptoms at any time after I begin using Semaglutide or Tirzepatide, I should immediately contact my provider. Unusual symptoms may include, but are not limited to, shortness of breath, edema (swelling of hands, legs or feet), heart palpitations or tachycardia (rapid heartbeat), nervousness, restlessness, insomnia, tremor, rapid breathing or respiration, or inability to tolerate exercise or activity. I understand that I may seek help from another qualified provider or go to a hospital emergency room.
I understand that I should use all prescribed medications in the manner prescribed by the provider and not provide this medication to any other person. I understand that I should not increase my dosage of any prescribed medication or use it with any other drug or substance without the recommendation of my provider. I also understand that I may stop using any prescribed medication at any time in the future but should notify my provider before doing so.
4. I understand that if I am pregnant or I suspect I may be pregnant or I am trying to conceive, I should not be taking prescription appetite medications. I will notify Prevention Center USA if I have any missed or irregular periods. I will use double-barrier protection methods against conception while on appetite suppressant medications.
5. I understand it is my responsibility to follow the instructions carefully and to report to the provider treating me for my weight any significant medical problems that I think may be related to my weight control program as soon as reasonably possible.
6. I understand that it is important to fully inform my surgical team about all of the medications I am taking before any surgical procedure. I will stop taking all medications prescribed to me by Prevention Center USA for at least 30 days prior to any surgery I may have.
7. I understand the purpose of this treatment is to assist me in my desire to decrease my body weight and to maintain this weight loss. I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I also understand that I will have to continue watching my weight all of my life if I am to be successful. I understand my continuing to receive the appetite suppressant will be dependent on my progress in weight reduction and weight maintenance. I agree that medications may be sent to my provider on my behalf to be distributed to me.