THE HAPPINESS PSYCHIATRIST®:
SHEENIE AMBARDAR, M.D.

Concierge Telepsychiatry, Teletherapy, Medical Weight Care & Coaching

(424) 666-8058

www.happinesspsychiatrist.com

Serving California and New York

 

 

MEDICAL WEIGHT MANAGEMENT CONSENT FOR TREATMENT

Please read and sign below.

 

We understand that managing weight can be a challenge, especially if you're dealing with binge eating, emotional eating, or food chatter. At The Happiness Psychiatrist®, we offer GLP-1/GIP medications as a potential tool to help adults on their weight management journey. Here are some brand names of these medications: Ozempic®, Mounjaro®, Rybelsus®, Trulicity®, Victoza®, Zepbound™, and Wegovy®

 

It's important to make sure these medications are a good fit for you. Please note that you should not take GLP-1/GIP medications if:

 

- You have a personal or family history of Thyroid C-Cell Tumors. More specifically, a personal or family history of Medullary Thyroid Carcinoma (MTC).

- You have a history of Multiple Endocrine Neoplasia Syndrome type 2 (MEN 2). 

- You are pregnant or plan to become pregnant while taking this medicine. 

- You are diabetic and/or taking any medications related to lowering your blood sugar levels without speaking to your endocrinologist or PCP first. GLP-1/GIP medications lower blood glucose and can cause hypoglycemia (low blood sugar); this effect can be multiplied when combined with other blood sugar-lowering medications, such as insulin.

- You have a history of pancreatitis or have a condition that may make pancreatitis more likely to occur. 

- You have a history of gallbladder disease. 

- You have kidney disease or are on dialysis. 

- You are allergic to any GLP-1 agonist such as: Adlyxin®, Byetta®, Bydureon®, Mounjaro®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy®, Zepbound™, or compounded semaglutide or tirzepatide.

- You are taking any other GLP-1/GIP agonist medication.

- You have other concerning allergies. Serious hypersensitivity (allergic) reactions (e.g. anaphylaxis, angiodedema) have been reported with GLP-1 medication. 

- You have a history of diabetic retinopathy.

 

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The following side effects may occur as a result of taking a

GLP-1/GIP medication:

Nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dyspepsia, dizziness, abdominal distension, belching, burping, low blood sugar, flatulence, gastroenteritis, gastroesophageal reflux disease (GERD), nasopharyngitis (runny nose), and/or common injection site reactions characterized by itching or burning at the site of administration with or without thickening of the skin (welting).

Medical Weight Management Services & Fees:

 

Initial 75-Minute Medical Weight Management Evaluation: This is the first integrative telehealth visit you will have with Dr. Ambardar in which she will review your full medical, psychiatric, psychosocial, and family history. An accurate medical history is important to obtain because certain weight management medications are contraindicated in patients with Type 1 Diabetes, Thyroid Cancer, Multiple Endocrine Neoplasia Syndrome Type 2 (MEN 2), or pregnancy. Before this visit, please remember to complete the Medical Weight Management Intake Form so that we will be able to make the best use of our time. During this session, your reason(s) for seeking treatment will be discussed in depth and a full treatment plan (including blood work, potential medications, and lifestyle adjustments) will be prescribed. Fee: $750

 

Medical Weight Management Follow-Up: 50-Minute Psychotherapy + Medication Management: During this dual-purpose, customized follow-up session, we will adjust and alter your weight management medication as needed, as well as engage in intensive psychotherapy. Dr. Ambardar's general treatment principle regarding weight management medications is to use the lowest effective dose of medication that successfully helps you reach your weight management goals. Regarding psychotherapy, specific treatment modalities used during sessions include psychodynamic or insight- oriented therapy, solution-focused therapy, cognitive-behavioral therapy, interpersonal therapy, inner child work, and journal therapy. During these sessions, we will explore the symbolism of what specific foods might mean to you and how you can have a more peaceful relationship with food as well as yourself. Fee: $450

 

Medical Weight Management Follow-Up: 25-Minute Medication Management + Psychotherapy: During this follow-up session, we will adjust your weight management medication as needed as well as review your treatment progress. Your food and weight goals will be discussed thoroughly, appropriate medication changes will be made, and supportive psychotherapy will be performed. Fee: $300

 

Other Professional Services: Professional services such as letter writing, completing prior authorizations, filling out certified medical forms, telephone calls, extensive email conversations, preparation of treatment summaries, or time spent performing any other functions are charged $150 for each 15-minute increment.

 

In order to continue receiving prescriptions for weight management medications, you agree to be seen for a telehealth appointment at least every month. In addition, if asked, you agree to check your blood pressure, weight, labs, and other vital signs between appointments. We appreciate your cooperation and look forward to helping you achieve your health goals. 

 

By signing below, I certify that I have read and understood the contents of this consent form. I am aware of the possible side effects of GLP-1/GIP medications and I give my consent for potential treatment. I have informed Dr. Ambardar of any known allergies to drugs or other substances, and any past adverse reactions I’ve experienced. I have informed Dr. Ambardar of all medications and supplements I’m currently taking. I understand that no guarantees have been made to me concerning my weight and food-related results. I agree to release The Happiness Psychiatrist Dr. Sheenie Ambardar, MD Inc. from all medical liability related to any and all care.