Jersey Medical Weight Loss Center

PHYSICIAN / ASSOCIATES DECLARATION: I have explained the contents of this document to the patient and have answered all the questions to the best of my knowledge. The patient has been adequately informed of the

• Benefits and risks associated with the use of the appetite suppressants/AOM
• Benefits and risks associated with alternative therapies.
• Risks associated with oveweight/obesity. After being adequately informed, the patient has consented to the recommended weight loss treatment. 

Signature of Dr. Aparna Chandrasekaran

Weight Loss Program Consent Form

 
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY :

Appetite Suppressant/Anti-Obesity Medication Informed Consent:

1. I understand that I'm being prescribed appetitie suppressant/anti-obesity medication (AOM) to assist me with weightloss and long-term weight management. These medications are intended to be used in combination with lifestyle modifications as recommended by my physician.

2. Medications, including the appetite suppressants, have labeling approved by Food and Drug Administration. This labeling contains suggestions for using the medication. The appetite suppressant labeling is generally based on shorter-term studies (up to 12 weeks) using the dosage indicated in the labeling.

3. My physician based on her experience, the experience of his colleagues in the field of obesity medicine and other factors have found appetite suppressants helpful for periods far more than 12 weeks or at doses in excess of those in the manufacturer's label. Such usage has not been as systematically studied as suggested in the labeling and it is possible as with many other medications, that there could be serious side effects. 

4. I understand that I may be prescribed a medication for a purpose,dosage or duration that is considered"off-label" which means that the medication is FDA-approved but its use for weight loss is not specially approved by FDA.

5. After consulting with my physician, I believe that the probability of risk is outweighed by the potential benefit of the appetite suppressant use for longer periods of time and when indicated in increased doses, also of the use of the "off-label" medications for weight loss. 

7. I affirm that I'm not pregnant, will report any pregnancy to my physician immediately. I understand that the anti-obesity medications are not safe during pregnancy or breastfeeding and must be stopped if pregnancy occurs.

RISKS & SIDE EFFECTS WITH APPETITE SUPPRESSANT/AOM: I understand that the use of appetite suppressant for more than 12 weeks and in higher dose than the dose indicated in the labeling involves some risks and hazards. The side effects associated with the appetite suppressant/AOM that is prescribed to me was explained by my physician. I understand that rare, unknown side effects may occur and on occasion be serious or fatal.

RISK ASSOCIATED WITH OVERWEIGHT/OBESITY: I am aware that there are many health risks associated with obesity like hypertension,diabetes, heart attack/stroke, sleep apnea etc. I understand that these risks increase significantly with increasing body weight. 

NO GUARANTEES: I understand that individual results vary and weight loss is not guaranteed. 

PATIENT RESPONSIBILITIES: I agree to provide accurate medical history, disclose all medications use,follow the dosing/administration instructions exactly, follow the recommendations of the physician,attend the follow-up visits as advised, and report any side effects/concerns promptly.

VOLUNTARY CONSENT: I have read and fully understand this consent form. I acknowledge that:

• The risks, benefits, alternatives, possible compliactions/consquences have been explained to me
• All my questions have been answered 

I authorize Dr.A. CHANDRASEKARAN and her associates to assist me with my weight loss .Hence, I voluntarily consent to the weight loss treatment at Jersey Medical Weight Loss Center.

For FL patients only, I have read and fully understand the Weight Loss Consumer Bill Of Rights ( FL Statute 501.0575)

 

 

                                        PAYMENT AGREEMENT

 

 I accept personal responsibility for the payment of the professional fees for the weight loss services.

 I understand that the medical weight loss treatment may not be 100% reimbursable by my health insurance plan.

 I understand that it is my responsibility to know and understand my insurance policy and its coverage benefits.

 I acknowledge that I am financially responsible for non-covered services, which includes but not limited to, Body Composition Analysis (BCA), meal replacement products, dietary supplements, and vitamin injections.

 I agree not to resell any of the meal replacement products/dietary supplements purchased from Jersey Medical Weight Loss Center

 I am aware that the meal replacement products cannot be returned or exchanged.

 All payments made to Jersey Medical Weight Loss Center are non-transferable and non-refundable.

I have read and fully understand this agreement. The foregoing terms are acceptable to me.