BOTTUMZUPWEIGHTLOSSPatient Clinic Policies

PATIENT CONSENT FOR WEIGHT LOSS THERAPY AND TREATMENT WITH (Bottumzup Health and Wellness, LLC)

If you have any questions, please feel free to ask us. Please initial each point acknowledging you understand that:

Health insurance typically does not cover services provided at (Bottumzup Health and Wellness LLC) want to seek insurance reimbursement, we would be happy to provide you itemized that you can submit to your insurance company.

I understand that treatments used at Bottumzup Health and Wellness LLC might not be considered a necessity. Treatments rendered are for the purpose of improving your quality of life hormone restoration, nutritional and supplemental counseling, and weight loss treatment.

I agree that if I am having any side effects or become sick, that I will follow up with my care provider or go to an urgent care or emergency department. primary care provider or go to an urgent care or emergency department. I agree that if I am having any side effects or become sick, that I will follow up with my I acknowledge that (Bottumzup Health and Wellness LLC) and (KAREN MOLINA MELENDEZ) are not my primary care provider unless I elect them so. I agree that I will continue with routine care through my primary care provider and notify them of treatments prescribed at (Bottumzup Health and Wellness LLC)

I acknowledge that (Bottumzup Health and Wellness LLC) and (KAREN MOLINA MELENDEZ) are primary care provider unless I elect them so. I agree that I will continue with routine care my primary care provider and notify them of treatments prescribed at (Bottumzup Health and Wellness LLC)

I understand that there are no refunds for services or products rendered. We cannot back used medications once they have been dispensed per state regulation.

I understand that there are NO REFUNDS for services or products rendered. We cannot accept back used medications once they have been dispensed per state regulation.

I understand that having an appointment with (Bottumzup Health and Wellness LLC) does not entitle me to being issued a prescription for hormone replacement, weight loss or additional medications. Every individual is different, and it is at the medical discretion to issue a prescription.

I understand that I must maintain my follow up appointments to remain on treatment. Itis important that lab work is monitored regularly for safety purposes. It is important that(KAREN MOLINA MELENDEZ) manages my treatment and it is at their discretion to provide.

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

I am voluntarily requesting treatment with (Bottumzup Health and Wellness LLC) and (KAREN MELENDEZ) in regards to weight loss therapy as determined by a mutual decision myself and the medical provider even if my hormone levels are considered to be in range for my age based off of other medical society recommendations and guidelines or considered overweight and not obese.

I do not hold any medical practitioner of (Bottumzup Health and Wellness LLC) responsible for age related preventive care. I agree that I will follow up with my primary care to obtain these screenings and I hold (Bottumzup Health and Wellness LLC) and (KAREN MOLINA harmless if an adverse event occurs during my treatment. I will ensure that my care provider provides the results of such screenings to (Bottumzup Health and Wellness LLC) as this the treatment prescribed to me.

I have read, understand and agree to all of the above statements.

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