WEIGHT LOSS PROGRAM CONSENT FORM

I authorize Dr. Sonya Johnson  and associated health care providers, to help me in
my weight-reduction efforts. I understand that my program may consist of a
balanced-deficit diet, a regular exercise program, instruction on behavior
modification techniques, and may involve the use of anti-obesity medications. Other
treatment options may include a very low-calorie diet or a protein-supplemented
diet. I further understand that if medications are used, they have been used
safely and successfully in private medical practices with experienced obesity medicine
specialists as well as in academic centers for periods exceeding those
recommended in the product literature.

I understand that any medical
treatment may involve risks as well as the proposed benefits. I also understand
that there are certain health risks associated with having excess weight or
obesity. Risks of this program are usually temporary, reversible, and may include
but are not limited to nervousness, sleeplessness, headaches, electrolyte
abnormalities, dry mouth, gastrointestinal disturbances, weakness, fatigue, pancreatitis,
psychological problems, gallstones, high blood pressure, rapid or slowing of
the heartbeat and heart irregularities, and risk of weight regain. These and
other possible risks could, on occasion, be serious or even fatal. Risks
associated with remaining overweight are high blood pressure, diabetes, heart
attack and heart disease, arthritis of the joints, including hips, knees, feet
and back, sleep apnea, and sudden death. I understand that these risks may be
modest if I am not significantly overweight but will increase with additional
weight gain over time.

I understand that much of the
success of the program will depend on my efforts and that there are no
guarantees that the program will be successful. I also understand that obesity is
a chronic, lifelong condition that may require changes in eating habits and
permanent changes in behavior to be treated successfully.

I have read and fully
understand this consent form and it has been fully explained to me. My
questions have been answered to my complete satisfaction.

Patient Consent Form for the Use of GLP-1 Receptor Agonist :Semaglutide/Tirzepatide

I understand and acknowledge the following information before starting the use of GLP-1 Receptor Agonist: Semaglutide/Tirzepatide):

Warnings:
1. GLP-1 Receptor Agonist may cause tumors in the thyroid, including thyroid cancer. Symptoms to watch for include a lump or swelling in the neck, hoarseness, trouble swallowing, or shortness of breath. If any of these symptoms occur, I will inform my healthcare provider immediately.
2. I should not use GLP-1 Receptor Agonist if I or any of my family members have a history of medullary thyroid carcinoma (MTC), a type of thyroid cancer.
3. I should not use GLP-1 Receptor Agonist if I have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
4. I should not use GLP-1 Receptor Agonist if I have had a serious allergic reaction to tirzepatide or any of the ingredients in GLP-1 Receptor Agonist.

Possible Side Effects:
1. Severe stomach problems: I should inform my healthcare provider if I experience severe or persistent stomach problems.
2. Kidney problems: Diarrhea, nausea, and vomiting may lead to dehydration and kidney problems. I should ensure to drink fluids to prevent dehydration.
3. Gallbladder problems: I should immediately inform my healthcare provider if I experience symptoms such as upper stomach pain, fever, yellowing of skin or eyes, or clay-colored stools.
4. Inflammation of the pancreas (pancreatitis): If I experience severe stomach pain that does not go away, with or without vomiting, I should stop using GLP-1 Receptor Agonist and contact my healthcare provider immediately.
5. Serious allergic reactions: In case of symptoms such as swelling of the face, lips, tongue or throat, difficulty breathing or swallowing, severe rash or itching, fainting, dizziness, or rapid heartbeat, I should stop using GLP-1 Receptor Agonist and seek immediate medical help.
6. Low blood sugar (hypoglycemia): The risk of low blood sugar may increase if I use GLP-1 Receptor Agonist with certain other diabetes medications. Symptoms of low blood sugar include dizziness, sweating, confusion, headache, blurred vision, slurred speech, shakiness, fast heartbeat, anxiety, irritability, hunger, weakness, or feeling jittery.
7. Changes in vision in patients with type 2 diabetes: I should inform my healthcare provider if I experience any changes in vision during treatment with GLP-1 Receptor Agonist.
8. Depression or thoughts of suicide: I should pay attention to any changes in my mood, behaviors, feelings, or thoughts. If I notice any new, worsening, or concerning mental changes, I should contact my healthcare provider immediately.

Common Side Effects:
The most common side effects of GLP-1 Receptor Agonist include nausea, diarrhea, vomiting, constipation, stomach pain, indigestion, injection site reactions, fatigue, allergic reactions, belching, hair loss, and heartburn. If any of these side effects bother me or do not go away, I should discuss them with my healthcare provider.

Before Using GLP-1 Receptor Agonist:
1. My healthcare provider will provide instructions on how to use GLP-1 Receptor Agonist before I start using it.
2. I should inform my healthcare provider if I am taking any diabetes medications, including insulin or sulfonylureas, as they may increase the risk of low blood sugar.
3. If I take birth control pills orally, I should consult my healthcare provider before using GLP-1 Receptor Agonist, as it may affect the effectiveness of birth control. Alternative forms of birth control may be recommended for a specific period.
4. I should discuss the following with my healthcare provider:
- Other medical conditions, including pancreas or kidney problems, or severe stomach issues such as gastroparesis or digestion problems.
- Other prescription medications, over-the-counter drugs, vitamins, or herbal supplements that I am currently taking.
- History of diabetic retinopathy.
- Pregnancy, plans to become pregnant, breastfeeding, or plans to breastfeed.

I confirm that I have read and understood the above information regarding GLP-1 Receptor Agonist (GLP-1 RA) and its potential risks and side effects. I have had the opportunity to discuss any concerns or questions with my healthcare provider. I voluntarily consent to the use of GLP-1 Receptor Agonist and agree to follow all instructions and guidelines provided.

RULES FOR USE OF ANTI-OBESITY CONTROL MEDICATIONS

NOTE:
SIGNING THIS FORM DOES NOT GUARANTEE THAT YOUR PROVIDER AT  IRIE NATUAL CENTER FOR HEALTH WILL FIND YOU TO BE AN APPROPRIATE CANDIDATE FOR ANTI-OBESITY
MEDICATIONS, BUT ONLY THAT YOU HAVE READ, UNDERSTOOD, AND AGREE TO THE TERMS OF
MEDICATION USAGE SHOULD YOU AND DR. SONYA JOHNSON DECIDE UPON THEIR USAGE NOW OR IN THE FUTURE.

Many anti-obesity medications are considered “controlled medications.” By law, a
controlled medication can only be prescribed from one facility at a time;
therefore I agree that only IRIE NAUTAL CENTER FOR HEALTH  will prescribe anti-obesity medications for me. I agree that it is my responsibility
to inform my physician(s) at IRIE NAUTRAL CENTER FOR HEALTH and any
other providers from whom I receive treatment of all medications prescribed to
me. I understand that the use of anti-obesity
medications is contra-indicated with certain medical histories, allergies, or
other medication use. I agree that I will be completely honest in
disclosing this information and will notify my physician(s) at IRIE NATUAL CENER FOR HEALTH of any changes to my medical history or medication
usage. I understand that failure to do so can be dangerous to my health.

I agree to take the medication only as prescribed and directed by Dr. Sonya Johnson. I understand that taking medications in any way other than as directed
and prescribed could affect my health and be dangerous. I also understand that
medications are typically considered after a trial of failed weight loss with
only nutritional/behavior modifications. If I am deemed a candidate for the
medication program at IRIE NAUTRAL CENTER FOR HEALTH, I am aware that
the lowest effective dosage will be tried prior to increasing dosages.

I
understand that medication prescriptions can be filled at a pharmacy of my
choice. I agree to use only one pharmacy at a time to fill any scheduled anti-obesity
prescriptions, and I give my permission for  IRIE NATURAL CENTER FOR HEALTH
to notify area pharmacies of the terms of this agreement.

I
will not share, sell, or trade my medication with anyone. I understand that
doing so is illegal and will result in my discharge from the care of IRIE NATURAL CENTER FOR HEALTH.  

I
understand that the use of some of the anti-obesity medications beyond 12 weeks
is considered “off label” or not initially approved by the U.S. Food and Drug
Administration (FDA). I understand that my physician(s) at IRIE NATURAL CENTER FOR HEALTH  are experienced specialist(s) in obesity medicine who will, at times, elect/choose, when indicated, to use the anti-obesity
medication(s) for longer periods of time as deemed appropriate for my individual
treatment.

I
understand that I am to report any side effects or adverse reactions of my
medications to the physician(s) at IRIE NAUTRAL CENTER FOR HEALTH.

I
understand that it is my responsibility to follow the instructions carefully
and that the purpose of this treatment is to assist me in my desire to decrease
my body weight for improvement of health and to maintain weight loss. I
understand that the purpose of medications for weight loss is to be used as an
adjunct to a program that includes nutrition and/or physical activity and/or
behavior modification.

I
agree that my physician at IRIE NATURAL CENTER FOR HEALTH  may
sometimes taper and/or stop my medication to evaluate its effect on my weight
loss and/or hunger and health. 

I
understand that much of the success of the program will depend on my efforts
and that there are NO GUARANTEES in
medical treatment in the disease of obesity. I also understand that I will have
to continue monitoring my weight after active weight loss.

Informed Consent for the HCG Diet

I understand that this program involves a drastic weight loss and detoxification process, which can result in losing large amounts of fat in a shorter amount of time. I acknowledge that losing weight rapidly can release toxins into the system.

I understand that the HCG program requires patients to be in good overall health. Health assessment will be conducted through a history, physical examination, and basic blood work, if available. I acknowledge that not every patient is a good candidate for the HCG program, especially those with compromised liver and kidney function and those taking multiple medications.

I understand that regular clinic visits are required throughout the program. I will visit the clinic on a weekly basis for the first two weeks, and then every other week for the remaining part of the diet. I will report any unusual symptoms to the physician during these visits. These follow-up visits will include checking blood pressure and heart rate and receiving a vitamin B injection.

I am aware that the HCG weight loss program involves a low-calorie diet alongside the administration of the hormone HCG (human chorionic gonadotrophin). I understand that HCG can be administered by injection under the skin. The combination of hormone and diet encourages the release of stored body fat.

I acknowledge that starting the diet may result in certain symptoms such as loss of energy, irritability, low-grade headache, constipation, hunger, and other mild symptoms. I understand that these symptoms typically subside around day 7 to 10 of the diet. I will report to the physician if these symptoms have not improved by day 14.

I understand that if I am taking blood pressure or blood sugar diabetic medication, I need to regularly monitor my blood pressure and blood sugar at home. I will always report to my physician if my blood pressure drops to near 100/70 or if my blood sugar drops to near 70.

I am aware that the HCG weight loss program is one of many therapies used in weight loss and that there are alternative treatments available. I understand that there is currently no well-constructed scientific data demonstrating the effectiveness of the HCG program. However, I acknowledge that there is empirical evidence from satisfied doctors and patients around the world that supports the viability and effectiveness of this treatment option.

I have been informed of the risks, side effects, and complications associated with rapid weight loss and the HCG diet. I understand that rare and unusual symptoms caused by detoxification may include shortness of breath, heart palpitations, nausea and vomiting, severe fatigue, swelling and severe itching, and dizziness.

I acknowledge that the risks and complications of the HCG diet may include no benefit from treatment, allergic reaction to the substance (although extremely rare), and infection at the injection site (although extremely rare).

I have had the opportunity to ask questions and seek clarifications regarding the HCG diet weight loss program, and I am satisfied with the information provided. I voluntarily provide my consent to participate in the HCG program.

Intermuscular Injection B12 & MIC Consent Form 

 I understand that these injections (B12, MIC) are commonly used to assist with weight loss and improve overall health. Before proceeding with the injections, I have been provided with the following information:

Benefits:
1. Increased energy levels
2. Improved metabolism
3. Enhanced fat burning capabilities
4. Boosted immune system
5. Enhanced overall well-being

Risks:
1. Allergic reaction to the injection
2. Pain or discomfort at the injection site
3. Infection at the injection site
4. Bruising or bleeding at the injection site

Side Effects:
1. Nausea or upset stomach
2. Headaches
3. Dizziness
4. Skin rash or itching
5. Swelling or redness at the injection site

Complications:
1. In rare cases, anaphylaxis or severe allergic reaction may occur. Symptoms of anaphylaxis may include difficulty breathing, swelling of the face or throat, rapid heartbeat, and hives. If any of these symptoms occur, emergency medical attention should be sought immediately.

I understand that the benefits, risks, side effects, and complications mentioned above are not exhaustive, and there may be other unknown risks. I have had the opportunity to ask questions and have received satisfactory answers regarding the injections and their associated risks.

I acknowledge that the injections will be administered by a trained healthcare professional at [Your Clinic Name]. I understand that I have the right to refuse or discontinue the injections at any time.

I hereby release IRIE Natural Health Center and its staff, and healthcare providers from any liability arising from the administration of these injections, except for instances of negligence or intentional misconduct

Patient Consent Form for Telemedicine Services

Telemedicine involves the use of electronic communications, including video and audio, to provide medical services remotely. This form is designed to help you understand and give your consent to the use of telemedicine in your medical care.

Benefits of Telemedicine:
- Increased access to medical care, especially for patients who may have difficulty traveling to the clinic.
- Convenience and flexibility in scheduling appointments.
- Reduced waiting times and improved efficiency in receiving medical services.
- Potential cost savings for both patients and healthcare providers.

Limitations and Risks:
- The telemedicine platform may have limitations in terms of audio and video quality, which could affect the ability to conduct a thorough examination or assessment.
- The transmission of medical information through electronic means carries certain risks, including the possibility of unauthorized access or breaches of confidentiality.
- In some cases, telemedicine services may not be appropriate for certain medical conditions or emergencies that require immediate in-person care.

Consent to Telemedicine Services:
By signing this form, I acknowledge and consent to the following:

1. I understand that telemedicine involves the use of electronic communications to provide medical services remotely.
2. I have been informed about the potential benefits, limitations, and risks associated with telemedicine.
3. I have the right to refuse or discontinue telemedicine services at any time without affecting my access to in-person medical care.
4. I understand that the privacy and confidentiality of my medical information will be protected to the best extent possible, but there may be risks associated with the transmission of medical data through electronic means.
5. I agree to provide accurate and complete information during telemedicine consultations and to inform the healthcare provider of any changes in my health status.
6. I understand that telemedicine services may not be appropriate for all medical conditions and emergencies, and that the healthcare provider may recommend an in-person visit or referral to another healthcare professional if necessary.
7. I understand that telemedicine services may involve the recording and storage of my medical information for documentation and continuity of care purposes

Patient Consent Form for Appointment Reminders and Text Messaging

Our medical practice aims to provide efficient and timely communication with our patients. This consent form is designed to help you understand and give your consent to receive appointment reminders and text messages from our clinic.

Appointment Reminders:
- We may use automated systems to send appointment reminders via SMS text messages or voice calls to the phone number provided.
- These reminders may include information about upcoming appointments, rescheduling, or cancellations.
- Standard message and data rates may apply, depending on your mobile carrier plan.

Text Messaging:
- We may use SMS text messaging to communicate with you regarding non-urgent matters, such as test results, prescription refill requests, or general information about our practice.
- Please note that text messaging should not be used for urgent or emergency communications. If you have a medical emergency, please call 911 or seek immediate medical attention.

Consent to Receive Messages:
By signing this form, I acknowledge and consent to the following:

1. I understand that I have the right to receive appointment reminders and non-urgent text messages from IRIE NATURAL CENTER FOR HEALTH to the contact information provided.
2. I authorize IRIE NATURAL CENTER FOR HEALTH to communicate with me via automated SMS text messages or voice calls for appointment reminders and non-urgent communications.
3. I acknowledge that I am responsible for any message and data rates that may apply, depending on my mobile carrier plan.
4. I understand that I have the right to opt-out of receiving text messages at any time by notifying  IRIE NATURAL CENTER FOR HEALTH in writing or by contacting our office directly.

                                          HIPAA Disclosure and Consent

HIPAA Compliance Patient Consent Form (Required by the Health Insurance Portability and Accountability Act - 45 CFR Parts 160 and 164)

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.  The notice contains a patient's rights section describing your rights under the law.  You ascertain that by your signature that you have reviewed our notice before signing this consent.  

The terms of the notice may change, if so, your will be notified at your next visit to update your signature/date. 

You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1966) law allows for the use of information for treatment, payment, or healthcare operations. 

By signing this form, you consent to our use and disclosure of your protected health information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

- Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

- The practice reserves the right to change the privacy policy as allowed by law. 

- The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.

- The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.

- The practice may condition receipt of treatment upon execution of this consent. 

I authorize IRIE NATURAL CENTER FOR HEALTH and its providers to use and or disclose any medical information necessary to providers requesting consultation, laboratory and imaging services, and family or caretakers as I indicate using an appropriate Release of Information Form. 

- A full copy of the notice of privacy practices can be printed for you when you arrive at the office. 

The privacy compliance officer of IRIE NATURAL CENTER FOR HEALTH is Dr. Sonya Johnson and she can be reached at 480-341-9400. 

FINANCIAL POLICY

1. Payment is due at the time of service. 

2. Payment methods accepted are cash & credit cards.