use of appetite suppression medication, you are acknowledging that:
a.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. b. That your inability to lose weight is causing significant emotional distress C.You are choosing to enter this medically managed weight loss program voluntary and hold harmless (BOTTUMZUP, LLC, KAREN MOLINA MELENDEZ) for use of such medications.
13. You acknowledge that alcohol and illicit drug use is prohibited in the program. Drugs like cocaine and amphetamines when used in conjunction with appetite suppressants and other medications prescribed could cause in serious injury or death. The use of alcohol will also affect your results. (Please initial)
14. I understand that the physician and I will determine what my daily caloric intake will be at my initial visit. (Please initial)
15. I acknowledge that I 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. I understand the importance of routinely following up with (LLC NAME) to monitor my progress during treatment. I understand this is vital to the safety of the treatment program and certify that I will be returning monthly as prescribed. (Please initial)
16. I hereby authorize (BOTTUMZUP, LLC), (KAREN MOLINA MELENDEZ) NP and additional staff of (BOTTUMZUP, LLC) to evaluate me for admission into (BOTTUMZUP, LLC) weight management program and treat me accordingly. I consent to obtaining blood work before treatment if deemed necessary. I certify that I am signing this under my free will and am competent to make my own medical decisions. (Please initial)
17. I have reviewed the mentioned risks and have determined the benefits outweigh the possible risks associated with medically managed weight loss therapy with (BOTTUMZUP, LLC I release any claim in court or any type of complaint that could result from treatment with (BOTTUMZUP, LLC), (KAREN MOLINA MELENDEZ) and any other staff associated with (BOTTUMZUP, LLC) and will not hold liable any provider or staff of (BOTTUMZUP, LLC (Please initial)
18. I understand that treatment modalities utilized by (BOTTUMZUP, 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. I also understand that many of the medications being utilized within (BOTTUMZUP, LLC/KAREN MOLINA MELENDEZ) medically managed weight loss program