For all conditions you check boxes for please describe and explain treatment received and current status of medical ailment.

LEAVE BLANK IF IT DOES NOT APPLY

Father:

Mother:

Most recent vitals. Vitals must be within past 3 months, we can not assume the role of your primary care provider. If you don’t have a primary care provider, you can visit an urgent care center for clearance prior to starting our services:

I certify the information provided by me is accurate and providing false or misleading information could adversely affect healthcare care provided to me and I agree that if I provide inaccurate information, I agree to hold harmless medical providers for all claims that might result from such inaccuracies.

This agreement is entered into by and between Daniel Olivero, MD / NJ Weight Loss & Preventive Care Clinics PA, (hereinafter called "Physician") and Patient

A. Background

A change in the Social Security Act, effective January 1, 1998, permits Medicare beneficiaries and physicians to contract privately outside of the Medicare program. Under the law as it existed prior to January 1, 1998, a physician was not permitted to charge a beneficiary more than a certain percentage in excess of the Medicare fee schedule amount (limiting charge). The law now permits physicians and beneficiaries to enter into private arrangements through a written contract under which the Beneficiary may agree to pay the Physician more than that which would be paid under the Medicare program.

However, beneficiaries and physicians who take advantage of this provision are not permitted to submit claims or to expect payment for those services from Medicare. This agreement is limited to the financial agreement between Physician and Beneficiary and is not intended to obligate either party to a specific course or duration of treatment.

B. Obligations of Physician

1. Physician agrees to provide such treatment as may be mutually agreed upon by the parties and at mutually agreed upon fees.

2. Physician agrees not to submit any claims under the Medicare program for any items or services even if such items or services are otherwise covered by Medicare.

3. Physician acknowledges that (s)he will not execute this contract at a time when the Beneficiary is facing an emergency or urgent healthcare situation.

4. Physician agrees to provide the beneficiary or his/her legal representative with a copy of this document before items or services are furnished to the beneficiary under its terms.

5. Physician agrees to submit copies of this contract to the Clinics for Medicare and Medicaid Services (CMS), upon the request of the CMS.

C. Obligations of Beneficiary

1. Beneficiary or his/her legal representative agrees to be fully responsible for payment of all items or services furnished by Physician and understand that no reimbursement will be provided under the Medicare program for such items or services.

2. Beneficiary or his/her legal representative acknowledges and understands that no limits under the Medicare program (including the limits under section 1848 (g) of the Social Security Act) apply to amounts that may be charged by Physician for such items or services.

3. Beneficiary or his legal representative agrees not to submit a claim to Medicare unless the filing of such claim is required to obtain secondary coverage for Physician’s charges. Beneficiary agrees not to ask Physician to submit a claim to Medicare

4. Beneficiary or his/her legal representative understands that Medicare payment will not be made for any items or services furnished by Physician that would have otherwise been covered by Medicare if there were no private contract and a proper Medicare claim had been submitted.

5. Beneficiary or his/her legal representative enters into this contract with the knowledge and understanding that he/she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and that the Beneficiary is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted out of Medicare.

6. Beneficiary or his/her legal representative understands that Medigap plans (under section 1882 of the Social Security Act) do NOT, and other supplemental insurance plans may elect not to, make payments for such items and services not paid for by Medicare.

7. Beneficiary or his/her legal representative acknowledges that the Clinics for Medicare and Medicaid Services (CMS) has the right to obtain copies of this contract upon request.

D. Physician's Status
Beneficiary or his/her legal representative further acknowledges his/her understanding that Physician [has not] been excluded from participation under the Medicare program under section 1128, 1156, 1892 or any other section of the Social Security Act.

I request injections of hCG along with strict dietary restrictions for the purpose of weight loss. I understand that as part of the program, I will be given a limited physical you, orientation to the program with supporting materials and I will be instructed on how to administer the injections myself.

I understand that initial blood tests will be necessary to rule out any conditions that would disqualify me from the program. I will obtain these from my own physician or have them ordered through NJ Weight loss and Preventive Care Clinics PA and staff (hereafter NJ WEIGHT LOSS). I understand hCG is not FDA approved for weight loss as this application is considered “off-label use.”

I understand there is no medical evidence to support the use of hCG for this purpose. I agree that I am and will be under the care of another medical provider for all other conditions. NJ WEIGHT LOSS can work in conjunction with, but cannot replace, my regular primary care physicians, such as general practitioners or other specialists in family medicine or internal medicine.

I understand NJ WEIGHT LOSS can only prescribe hCG and medication necessary for this treatment and all other health matters should be through my regular physician(s). Prior to my treatment, I have fully disclosed any medical conditions or diseases such as pregnancy, trying to get pregnant, breastfeeding, history of gallbladder disease, diabetes, autoimmune diseases, HIV, heart disease, liver disease, kidney disease, uncontrolled high blood pressure, seizure disorders, blood disorder (anemia, thalessemia, hemophilia, etc.) emphysema or asthma, and any history of
stroke or cancer.

These contraindications have been fully discussed with me. If I fail to disclose any medical condition that I have, I release the doctor and facility from any liability associated with this treament.
While hCG is generally free of negative side effects, there is the possibility of the following:

* Ovarian Hyper-stimulation Syndrome (OHSS) – which is a life-threatening condition
* Arterial Thromboembolism - another potentially life-threatening condition
* Blood clots
* Risk of multiple pregnancies (twins, triplets, quadruplets, etc.)
* Abnormal enlargement of breasts in men (gynaecomastia)
* Over stimulation of the ovaries causing production of many ova (eggs) in women
* Acne
* Tiredness
* Changes in mood
* Irritation or skin rash in area of use
* Excessive fluid retention in the body tissues, resulting in swelling (edema)
* Hair loss
* Prostate hypertrophy
* Difficulty breathing
* Collapse
* Death
I understand hCG treatments may involve these risks and other unknown risks:

I understand that use of hCG is absolutely contraindicated during pregnancy and breastfeeding. I understand that it is my responsibility to inform NJ WEIGHT LOSS if I am pregnant, if I am trying to become pregnant or if I become pregnant during the course of these treatments.

I understand that hCG is used in infertility treatments, and therefore, I have an increased chance of pregnancy while on hCG. Multiple birth control methods should be used while on hCG. However, hCG is contraindicated for women using IUD for birth control. Therefore, I agree to use condoms and/or abstinence as birth control method for the duration of the diet.

I agree to immediately report any problems that might occur to my medical provider during the treatment program. I further understand that not complying with the dosage recommendations and dietary restrictions could increase risks and alter my results from the program. If I do not follow these recommendations and restrictions, I agree to release the doctor and facility from any liability arising as a result of this. Initials:

I understand that I may quit the program at any time. While adverse side effects or complications are not expected, in the event that an illness does occur, I understand that I need to contact NJ WEIGHT LOSS. If I experience an emergency situation, I understand that I need to go to an emergency facility.

I understand that if there are any changes in my medical history or there are any changes in my medications or any other changes relevant to this procedure, I will advise NJ WEIGHT LOSS at that
time.

I have read and fully understand the above terms. All my questions have been addressed to my satisfaction. I agree to release the doctor and the facility from any liability associated with this procedure. In the event a dispute arises over the outcome of the procedure, I consent solely to arbitration as a legal means of settlement (Arbitration Agreement Attached).

I acknowledge and understand that Daniel Olivero, MD and NJ WEIGHT LOSS is NOT my primary Medical Doctor and ALL medical decisions regarding any current or future health conditions should be addressed by my primary care physician. I have spoken to my primary care physician regarding the HCG Diet and he/she has no objections to my starting the program. NJ WEIGHT LOSS serves as only a resource for general wellbeing and preventive medicine and does NOT treat any existing
illness.

I acknowledge that there are no guarantees relating to the effectiveness of the HCG Diet and that I have done my own research and have made a well informed decision to start the diet and agree that NJ WEIGHT LOSS is not responsible for my individual performance or my ability to adhere to the diet.
There are NO guarantees for individual weight loss.

In fact, I acknowledge that I have done my own research and am requesting that the NJ WEIGHT LOSS provide the HCG Diet to me.

I am certain I’ll be ready to start diet when I start it. I acknowledge that any medical ailments or personal issues preventing adherence to diet is not the fault or responsibility of NJ WEIGHT LOSS.

I UNDERSTAND THERE ARE NO REFUNDS OR PARTIAL CREDITS.

NO EXPECTATION HAS BEEN GIVEN THAT PATIENT WILL LOSE A POUND PER DAY!! THAT IS OUR GOAL BUT NOT PROMISES HAVE BEEN MADE TO PATIENT!!
ACKNOWLEDGE & AFFIRM:

1) Daniel Olivero, MD / NJ Weight Loss & Preventive Care Clinics PA (hereafter “Medical Clinic”) is NOT my primary Medical Doctor;

2) All medical decisions regarding any current or future health conditions should be addressed by my primary care physician;

3) Medical Clinic serves as only a resource for general wellbeing and preventive medicine and does NOT treat any existing illness; all acute illnesses will be addressed by primary care physician NOT by
Medical Clinic.

4) All medical information supplied by me is accurate and forthcoming;

5) I have informed my primary care physician about services I am to receive at Medical Clinic and he/she has no objections to such services.

6) I have NOT been rushed into making any decisions and I have had ample opportunities to ask Daniel Olivero, MD and my primary care physician questions prior to receiving any treatment.

7) I acknowledge that Medical Clinic does not provide any promises or guarantees that the treatments I am to received will be effective in helping to improve my current health conditions and that in coming to Medical Clinic I had previously made a decision independent of Medical Clinic to try the services offered at Medical Clinic.

8) I understand that there are NO REFUNDS for any reasons.

9) I am not under any sort of pressure or duress because of a current medical condition and I have not been made any promises as to the results or effectiveness of such services/treatments and have been provided with detailed costs for services and I can afford the services I am requesting without creating a hardship for myself or those depending on me financially.

10) I authorize Medical Clinic to charge my credit card (amex, visa, mastercard or discover) to pay for services.

11) I consent to live encrypted audio & video monitoring (ie: webcam / FaceTime) during intake, IV Vitamin & Nutrient administration, physical exam and instructional sessions to Medical Director or other medical staff as necessary when off site.

LIMITATION OF SERVICES:
Daniel Olivero, MD / NJ Weight Loss & Preventive Care Clinics PA (hereafter “Medical Clinic”) does NOT treat any diseases and any services performed by staff, are designed to improve overall nutritional wellbeing of our patients. The HCG Diet requires daily injections to be administered to patient. No published studies have shown that the HCG Diet is effective. HCG has not been approved by FDA for weight loss.

Since 1975 the FDA has required all marketing and advertising of HCG to state the following: “HCG has not been demonstrated to be effective adjunctive therapy in the treatment of obesity. There is no substantial evidence that it increases weight loss beyond that resulting from caloric restriction, that it causes a more attractive or ‘normal’ distribution of fat, or that it decreases the hunger and discomfort associated with calorie-restricted diets.”

“HCG is a hormone extracted from urine of pregnant women. It is approved by FDA for treatment of certain problems of the male reproductive system and in stimulating ovulation in women who have had difficulty becoming pregnant. No evidence has been presented, however, to substantiate claims for HCG as a weight-loss aid.”

Patient agrees to consult with primary care physicians as to the safety and efficacy of the treatments provided by staff at Medical Clinic given their familiarity with patient’s underlying medical history and response to medications received. Patient has not been pressured to make any decision and I have had the opportunity to discuss all treatments proposed with my primary care physician and given the opportunity to ask questions.

Patient confirms he/she is making an informed decision based on all the information provided by Medical Clinic and my primary healthcare practioner(s) and I have had the opportunity to review any peer reviewed scientific journals that may have reported on the therapies proposed. Such journals can be reviewed for free at UMDNJ Library 30 12th Ave. Newark NJ, 07101, Phone: 973-972-4580 or accessed by subscribing online at http://www.questia.com

Treatments may have risk factors listed or cause the side effects listed below. However, as these treatments might be considered experimental in nature, as they may not have been funded for widespread scientific review under controlled conditions and have not been reported in peer reviewed scientific journals; there may be some side effects that we cannot predict.

WOMEN of Child Bearing Years: I certify that there is NO possible way that I could be pregnant. Women in child bearing years must receive pregnancy test ($20 extra) if they have had sexual intercourse since last menstrual period unless they have had a hysterectomy. I agree that I will avoid unprotected sex and use multiple methods of birth control during the time frame while on HCG Diet and not attempt to conceive children until 60 days after completing HCG DIET.

* The nature and purpose of a proposed treatment or procedure: Hcg Diet

* The benefits of a proposed treatment or procedure: Weight Loss

* Alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance): change diet, exercise, prescribed medication, OTC medications, surgery, psychiatric therapies

* The risks of not receiving or undergoing a treatment or procedure: stay the same or get worse

* The benefits of not receiving or undergoing a treatment or procedure: save money or condition may resolve itself

* The total costs of HCG Diet program have been discussed and alternative treatments listed above.

* HCG Diet: Side effects / Potential risks or discomfort: REMEMBER: ALL WOMEN WHO GET PREGNANT HAVE HAD HCG IN THEIR BODY AT FAR HIGHER LEVELS THAN THOSE TAKING HCG AS PART OF THE HCG DIET. Dehydration is common side effect of HCG Diet. Hair loss is a rare side effect of dieting especially with highly restrictive diets. Take supplements and consult your primary care MD if you have a history of hair loss. The HCG medication manufacturer reports that on rare occasions some patients taking HCG at HIGH levels 10,000+ I.U.’s (50 times the HCG Diet Dosage) may experience headaches, mood swings, depression, blood clots, confusion, and dizziness. Some women also develop a condition called Ovarian Hyperstimulation Syndrome (OHSS); symptoms of this include pelvic pain, swelling of the hands and legs, stomach pain, weight gain, shortness of breath, diarrhea, vomiting/nausea, and/or urinating less than normal. In some women, being on the HCG diet protocol and taking HCG, may cause delayed menstrual cycle, early menstrual cycle, heavier flow, lighter flow and or heavy cramping. These conditions also are symptoms that women may experience during pregnancy.

All Statements on these patient forms are accurate and true to the best of my knowledge. I understand that treatments will be based on the information provided herein. If I willingly withhold knowledge from my treating physician, I accept full liability from any consequences arising there from.

I certify that I have seen my primary care physician within the past year and that he /she has given me a physical exam, taken blood work (CBC & CMP) and taken my vital signs (all of which were within the normal range). I have discussed the hCG Diet and he/she believes that it is safe for me to engage in the activities of such and I will follow up with my primary care physician after completing the diet and will seek emergency medical care in the event that I have any unusual medical issues during my course of treatment.

I certify the information provided by me is accurate and providing false or misleading information could adversely affect healthcare care provided to me and I agree that if I provide inaccurate information, I agree to hold harmless medical providers for all claims that might result from such inaccuracies.

You are considering using Tirzepatide, a prescription medication, off-label for the purpose of weight loss. The use of Tirzepatide for weight loss is not FDA-approved, and there is limited research available on the safety and effectiveness of this treatment.

Tirzepatide also known as: Mounjaro.

Tirzepatide is a simple, once a week, subcutaneous injection (most people say they can’t even feel it with our super short and ultra thin insulin syringes) which contains the weight loss drug Tirzepatide and helps you lose weight.

Tirzepatide is a pharmaceutical drug initially developed to help people with diabetes controlling and lowering blood sugar levels. However, clinical trials have shown that Tirzepatide is also a safe and effective treatment for obese patients to aid weight loss.

We use Tirzepatide "off-label", which means we're using it for weight loss even though it's licensed for diabetes, because there's an abundance of clinical evidence that it's safe and effective for weight loss too.

Tirzepatide mimics a natural hormone in your body called GLP-1. This hormone is produced by your digestive system in response to eating food. It acts on both the brain and the digestive system to regulate how full you feel after a meal. It slows down the emptying of your stomach into the rest of your digestive system.

GLP-1 also regulates insulin secretion in response to eating meals so that your blood sugar is better controlled (even lowering blood sugar levels) and reduces your appetite by signaling to your brain that you've eaten a meal.

Tirzepatide acts just like this natural hormone to make you feel fuller for longer, reducing your cravings for more food, enhancing the way your body regulates blood sugar levels and the storage of fat. This can help patients lose weight.

You'll start on the lowest dose, 0.25mg, and then gradually increase over 8 weeks to the 1mg dose. This helps your body adjust to the medication in the first few weeks and reduces the severity of common side-effects m, such as nausea. Some people may require increased dosages to continue to lose weight, medical staff can consult with patient.

I acknowledge that there are no guarantees relating to the effectiveness of the Tirzepatide and that I have done my own research and have made a well informed decision to start this program and agree that NJ WEIGHT LOSS is not responsible for my individual performance or my ability to adhere to the diet. There are NO guarantees for individual weight loss.

NJ Weight loss and Preventive Care Clinics PA will prescribe Tirzepatide with B6 from a compounding pharmacy.

Vitamin B-6 (pyridoxine) is important for normal brain development and for keeping the nervous system and immune system healthy.

Food sources of vitamin B-6 include poultry, fish, potatoes, chickpeas, bananas and fortified cereals. Vitamin B-6 can also be taken as a supplement, typically as an oral capsule, tablet or liquid.

Purpose of the Consent: The purpose of this consent is to provide you with information about the off-label use of

Tirzepatide for weight loss, including its potential benefits and risks, so that you can make an informed decision about whether to use this medication.

Benefits of Using Tirzepatide for Weight Loss: Tirzepatide is thought to help regulate hunger and reduce the desire to eat, which may result in decreased food intake and weight loss. Some people may experience significant weight loss when taking Tirzepatide off-label for this purpose.

Risks of Using Tirzepatide for Weight Loss: While Tirzepatide may be effective for some people in promoting weight loss, it is important to be aware of the potential risks associated with using this medication for this purpose. Common side effects of Tirzepatide include nausea, diarrhea, changes in bowel movements, and stomach discomfort. In rare cases,

Tirzepatide may also cause more serious adverse reactions, including hypoglycemia (low blood sugar), pancreatitis (inflammation of the pancreas), and gallbladder problems.

Tirzepatide may cause serious side effects, including:
Possible thyroid tumors, including cancer. Tell your healthcare provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. In studies with rodents, Tirzepatide and medicines that work like Tirzepatide caused thyroid tumors, including thyroid cancer.

It is not known if Tirzepatide will cause thyroid tumors or a type of thyroid cancer called medullary thyroid carcinoma (MTC) in people.

Do not use Tirzepatide if you or any of your family have ever had a type of thyroid cancer called medullary thyroid carcinoma (MTC) or if you have an endocrine system condition called Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).

Do not use Tirzepatide if you have had a serious allergic reaction to Tirzepatide or any of the ingredients in Tirzepatide.

Before using Tirzepatide, tell your healthcare provider if you have any other medical conditions, including if you:
• have or have had problems with your pancreas or kidneys.
• have type 2 diabetes and a history of diabetic retinopathy.
• have or have had depression, suicidal thoughts, or mental health issues.
• are pregnant or plan to become pregnant. Tirzepatide may harm your unborn baby. You should stop using Tirzepatide 2 months before you plan to become pregnant or are breastfeeding or plan to breastfeed. It is not known if Tirzepatide passes into your breast milk.

Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Tirzepatide may affect the way some medicines work and some medicines may affect the way Tirzepatide works. Tell your healthcare provider if you are taking other medicines to treat diabetes, including sulfonylureas or insulin. Tirzepatide slows stomach emptying and can affect medicines that need to pass through the stomach quickly.

What are the possible side effects of Tirzepatide?

The most common side effects of Tirzepatide may include: nausea, diarrhea, vomiting, constipation, stomach (abdomen) pain, headache, tiredness (fatigue), upset stomach, dizziness, feeling bloated, belching, gas, stomach flu and heartburn.

Tirzepatide may cause serious side effects, including:
inflammation of your pancreas (pancreatitis). Stop using Tirzepatide and call your healthcare provider right away if you have severe pain in your stomach area (abdomen) that will not go away, with or without vomiting. You may feel the pain from your abdomen to your back.

Gallbladder problems. Tirzepatide may cause gallbladder problems, including gallstones. Some gallstones may need surgery.

Call your healthcare provider if you have symptoms, such as pain in your upper stomach (abdomen), fever, yellowing of the skin or eyes (jaundice), or clay-colored stools. increased risk of low blood sugar (hypoglycemia) in patients with type 2 diabetes, especially those who also take medicines for type 2 diabetes such as sulfonylureas or insulin. This can be both a serious and common side effect.

Talk to your healthcare provider about how to recognize and treat low blood sugar and check your blood sugar before you start and while you take Tirzepatide. Signs and symptoms of low blood sugar may include dizziness or light-headedness, blurred vision, anxiety, irritability or mood changes, sweating, slurred speech, hunger, confusion or drowsiness, shakiness, weakness, headache, fast heartbeat, or feeling jittery.

Kidney problems (kidney failure). In people who have kidney problems, diarrhea, nausea, and vomiting may cause a loss of fluids (dehydration) which may cause kidney problems to get worse. It is important for you to drink fluids to help reduce your chance of dehydration.

Stop using Tirzepatide and get medical help right away, if you have any symptoms of a serious allergic reaction, including swelling of your face, lips, tongue, or throat; problems breathing or swallowing; severe rash or itching; fainting or feeling dizzy; or very rapid heartbeat.

Change in vision in patients with type 2 diabetes. Tell your healthcare provider if you have changes in vision during treatment with Tirzepatide.

Increased heart rate. Tirzepatide can increase your heart rate while you are at rest. Tell your healthcare provider if you feel your heart racing or pounding in your chest and it lasts for several minutes.

Depression or thoughts of suicide. You should pay attention to any mental changes, especially sudden changes in your mood, behaviors, thoughts, or feelings. Call your healthcare provider right away if you have any mental changes that are new, worse or worry you.

It is important to keep in mind that the safety and effectiveness of using Tirzepatide for weight loss have not been established, and there is limited research available on this treatment.

Alternatives to Using Tirzepatide for Weight Loss: There are other treatments available for weight loss, including lifestyle changes (such as increasing physical activity and eating a balanced diet) and other prescription medications. Your healthcare provider can help you determine the best treatment option for you based on your individual needs and medical history.

Conclusion: By signing this informed consent, you acknowledge that you have been informed of the potential benefits and risks of using Tirzepatide off-label for weight loss, and that you understand that the safety and effectiveness of this treatment have not been established. You also understand that there are alternative treatments available for weight loss, and that your healthcare provider can help you determine the best treatment option for you.

Patient agrees to continually follow up with their Primary Care Physician and immediately seek emergency care from a hospital should emergent care be necessary for any condition that may develop whether related to Tirzepatide treatment or from any cause that should require treatment. Should any adverse reactions develop  Patient agrees to immediately discontinue Tirzepatide treatment and seek medical treatment.

Costs of Tirzepatide program:

The parties have discussed and agreed to pricing for starting and continuing Tirzepatide.

Patients self administer medication at home with easy to use pain free subcutaneous injections.

Tirzepatide: Generic Mounjaro Subcutaneous Injections once per week

DOSING:

2.5 mg (25 units in insulin syringe) once per week for 4 weeks initially; THEN increase to 5 mg per week (50 units in insulin syringe).

We advise most people should find reliable weight loss at maximum dose of 5mg per week (50 units on insulin syringe). If you would like to increase dosage above that please discuss with MD. Maximum safe dose 15mg per week for diabetes.

Strength in vial: 2.5 mg = 0.25ml = 25 units on insulin syringe

PLEASE NOTE: If you have done Tirzepatide (ie: Mounjaro) before, you will likely need to increase dosage as initial.

Costs of Tirzepatide may change and Patient shall not hold provider responsible for maintaining control of costs in the future.

Tirzepatide and syringes shipped to patients directly from the pharmacy after payment is received.

Nausea is a common side effect of Tirzepatide until patients get used to it. Approximately 30% of people complain of slight nausea when starting Tirzepatide. Symptoms typical resolve shortly thereafter.

If you would like us to include quick dissolve zofran to alleviate potential issues of nausea with your initial order, please let us know and we will advise pharmacy and let you know the additional costs.

I have been informed of the following:

• While all components generally have no side effects, doses must be taken at regular intervals. The injections are only effective temporarily. As soon as the effect of these drugs wear out, the body starts returning to normal.
• Some redness, minor discomfort, small bruising and bleeding at the injection site may occur. This will usually dissipate in a minimal amount of time.
• Some people have experienced allergic reactions to the injections.
• Potential side effects include stomach upset and urinary problems due to the strain the injections place on the kidneys. Some patients have been unable to control their urine and/or had diarrhea.
• Depression is another possible side effect.
• It has been reported that B12 can cause peripheral vascular thrombosis, itching, and a feeling of swelling in the body.
• Unexplained pain may develop in unrelated parts of the body. Some people have experienced joint pains.
• Lipotropic injections change the function of the digestive system temporarily. This can result in extreme exhaustion.
• Weight loss can be inconsistent from one week to the next. There can be no guarantees as to the timetable of a weight loss program.
• Too much Methionine and Adenosine Monophosphate can potentially accumulate in the body and have the side effect of boosting the metabolic rate too high. If any abnormal heart racing occurs, I will contact my medical provider immediately.
• Vitamin B12 is contraindicated in Leber’s hereditary optic neuritis, as it can cause blindness.

I will inform my practitioner of any changes in my medical history, current medications, and/or any changes relevant to this procedure prior to any future treatments.

I have read the above and I agree to accept the risk of the procedure. All my questions have been answered to my satisfaction. I agree to release the facility and the medical practitioner from any liability arising from the procedures. I consent solely to arbitration as a legal means of settlement.

BETWEEN: Patient & NJ Weight Loss and Preventive Care Clinics PA, shareholders, Staff, Agents, Representatives and Corporate Officers

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE & OTHER ISSUES DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL.

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice or any tort or cause of action between the parties arising from any communication in any form related to services rendered or not rendered and whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by New Jersey law, and not by a lawsuit or resort to court process except as New Jersey law provides for judicial review or arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided on a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or related to treatment or service provided or not provided or communications made between the parties in any form (in person, over phone, text message, fax, email etc.), including any family or heirs of the patient and the term “patient” herein shall mean the mother and the mother’s expected child or children.

All claims for monetary damages exceeding the jurisdictional limit of the small claims court and all class action cases against the physician, and the physician’s partners, associates, association, corporation or partnership, and the employees, agents and estates of any if them, must be resolved by means of binding arbitration before a single arbitrator in accordance with the then existing Commercial Arbitration Rules of the American Arbitration Association, including the Optional Rules for Emergency Measures of Protection. The arbitrator shall be a practicing attorney or retired judge with at least fifteen years total working experience as such. The arbitration shall be held in New Jersey or any other place agreed upon at the time by the parties. No demand for arbitration may be made after the date when the institution of legal or equitable proceedings based on such claim or dispute would be barred by the applicable statute of limitation. The arbitrator is not authorized to award punitive or other damages not measured by the prevailing party’s actual damages.

A party may apply to the arbitrator seeking injunctive relief until an arbitration award is rendered or the dispute is otherwise resolved. A party also may, without waiving any other remedy, seek from any court having jurisdiction any interim or provisional relief that is necessary to protect the rights or property of that party pending the arbitrator’s appointment or decision on the merits of the dispute. If the arbitrator determines that a party has generally prevailed in the arbitration proceeding, then the arbitrator shall award to that party its reasonable out-of-pocket expenses related to the arbitration, including filing fees, arbitrator compensation, attorney’s fees and legal costs.

Article 3: Procedures and Applicable Law: A demand for arbitration must communicate in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party’s own benefit. Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.

Article 4: Revocation: This agreement may be revoked by written notice delivered to the NJ Weight Loss and Preventive Care Clinics PA within 30 days of signing.

Article 6: Severability Provision: If any provision if this arbitration agreement is held invalid of unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.

NJ Weight Loss and Preventive Care Clinics PA and related parties

Agreed:

 

RN - Clinical Director

Company Representative

I authorize NJ Weight Loss and Preventive Care Clinics PA to use automated text/SMS and pre-recorded messages to my cell phone or home phone to confirm appointments, communicate about my medical issues, and inform me of discounts and marketing offers. Standard fees from your cell phone provider apply. I can opt out of such services at any time by sending "STOP" to any received text. There is no difference in services provided to those who do not sign up for texts.

Telehealth involves the use of electronic communications to enable providers at different locations to share individual client information for the purpose of improving client care.  Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:
• Client health records
• Live two-way audio and video
• Output data from health devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:
• Improved access to care by enabling a client to remain in his/her provider's office (or at a remote site) while the providers obtains test results and consults from practitioners at distant/other sites.
• More efficient client evaluation and management.
• Obtaining expertise of a distant specialist.

Possible Risks:
There are potential risks associated with the use of telehealth. These risks include, but may not be limited to:
• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate decision making by the providers and consultant(s);
• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal health information;
• In rare cases, a lack of access to complete health records may result in interactions or allergic reactions or other judgment errors;

By signing this form, I understand the following:

1. I understand that the laws that protect privacy and the confidentiality of health information also apply to telehealth, and that no information obtained in the use of telehealth which identifies me will be disclosed
to researchers or other entities without my consent.

2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.

3. I understand that I have the right to inspect all information obtained and recorded in the course of a telehealth interaction, and may receive copies of this information for a reasonable fee.

4. I understand that a variety of alternative methods of health care may be available to me, and that I may choose one or more of these at any time. My provider has explained the alternatives to my satisfaction.

5. I understand that telehealth may involve electronic communication of my personal health information to other practitioners who may be located in other areas, including out of state.

6. I understand that it is my duty to inform my provider of electronic interactions regarding my care that I may have with other healthcare providers.

7. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
Patient Consent To The Use of Telehealth

I have read and understand the information provided above regarding telehealth, have discussed it with my provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telehealth in my care.

I certify the information provided by me is accurate and providing false or misleading information could adversely affect healthcare care provided to me and I agree that if I provide inaccurate information, I agree to hold harmless medical providers for all claims that might result from such inaccuracies.

AGREED & ACCEPTED:

HIPAA Privacy Rule of Patient Authorization & Agreement
Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a))

I understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information serves as:
• a basis for planning my care and treatment;
• a means of communication among the health professionals who may contribute to my healthcare;
• a source of information for applying my diagnosis and surgical information to my bill;
• a means by which a third-party payer can verify that services billed were actually provided;
• a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals

I have been provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this facility’s notice prior to signing this authorization. I authorize the disclosure of my

Protected Health Information as specified below for the purposes and to the parties designated by me.

Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a))

I understand that:
• I have the right to review this facility’s Notice of Information practices prior to signing this consent;
• This facility, reserves the right to change the notice and practices and that prior to implementation will mail a copy of any revised notice to the address I’ve provided if requested;
• I have the right to request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that this facility is not required by law to agree to the restrictions requested.
• I may revoke this consent in writing at any time, except to the extent that this facility, has already taken action in reliance thereon.
• It is this facility’s procedure to share Protected Health Information with labs, x-rays, consulting physicians, and hospitals. We will call
the pharmacy of your choice regarding your prescriptions. We will only exchange minimum necessary Protected Health Information for each transaction.

CLINICAL JUSTIFICATION,
ASSUMPTION OF RISK & DOCUMENTATION
FOR TESTOSTERONE REPLACEMENT THERAPY (TRT)**
Provider:
NJ Weight Loss & Preventive Care Clinics PA (“Provider”)

1. Nature and Purpose of Treatment
I understand that I am being evaluated for and may receive Testosterone Replacement Therapy (TRT) for the treatment of clinically significant testosterone deficiency (hypogonadism). TRT may be administered via injection, topical, oral, implantable, or other medically accepted methods.

I acknowledge that TRT is prescribed only when supported by objective laboratory findings combined with clinically meaningful symptoms, and when deemed medically appropriate under New Jersey law.

2. New Jersey Standard of Care & Physician Discretion
I understand that under N.J.A.C. Title 13, licensed physicians in New Jersey may diagnose and treat testosterone deficiency using independent professional medical judgment.
I acknowledge that:
• The practice of medicine is not an exact science
• No outcomes are guaranteed
• TRT may be declined or discontinued at any time if medical criteria are not met

3. Diagnostic Criteria for TRT
I understand that TRT consideration requires both:

A. Objective Laboratory Evidence
• Consistently low total and/or free testosterone
• Properly timed and interpreted laboratory testing

B. Corresponding Clinical Symptoms
That are persistent, clinically relevant, and not better explained by other causes. Laboratory values alone or symptoms alone do not mandate treatment.

4. Conditions That Are NOT Medical Indications for TRT

I acknowledge TRT is not prescribed solely for:
• Athletic or performance enhancement
• Bodybuilding or cosmetic purposes
• Anti-aging or lifestyle optimization alone
• Weight loss without diagnostic hypogonadism
• Patient preference absent clinical justification

5. Primary Medical Doctor (PMD) Acknowledgment
I affirm that:
• I discussed TRT with my Primary Medical Doctor (PMD)
• My PMD has no objection to TRT and/or suggested evaluation
• Provider does not replace primary care
Provider reasonably relies on my representation regarding PMD involvement.

6. Potential Benefits of TRT (Not Guaranteed)
Potential benefits may include:
• Improved energy
• Improved libido and sexual function
• Increased lean muscle mass
• Improved bone density
• Mood or cognitive improvement
Individual response varies and benefits are not guaranteed.

7. Risks and Potential Adverse Effects
I understand TRT risks include, but are not limited to:
• Polycythemia (elevated hematocrit)
• Acne, oily skin
• Gynecomastia
• Fluid retention
• Worsening sleep apnea
• Suppression of endogenous testosterone
• Testicular atrophy and infertility
• Lipid changes
• Prostate-related effects
• Possible cardiovascular risks
Long-term risks continue to be studied.

8. Monitoring and Compliance
I understand TRT requires:
• Ongoing lab monitoring
• Clinical reassessment
• Dose modification or discontinuation if indicated
Failure to comply may result in termination of therapy.

9. Financial Disclosure
I acknowledge that:
• Provider does not accept insurance
• TRT is self-pay
• All pricing and financial terms were discussed and agreed to outside this agreement
• Financial considerations did not influence medical decision-making

I certify that the name displayed above is my full legal name and that I am the individual authorized to sign this document. I understand that this electronic signature carries the same legal force and effect as a handwritten signature.

Reported effects (check all):

I affirm that TRT is not sought or prescribed for:
• Athletic or bodybuilding enhancement
•Cosmetic or lifestyle purposes
•Competitive sports
• Social or influencer motivations
.Misrepresentation constitutes grounds for immediate discontinuation

To the fullest extent permitted by New Jersey law, I assume all risks associated with TRT and release Provider from claims arising out of treatment, except where prohibited by law (gross negligence or willful misconduct). This agreement is governed by New Jersey law. Disputes are subject to binding arbitration, if applicable.

PATIENT CERTIFICATION
I certify that:
•I read and understand this document
• My questions were answered
•I am signing voluntarily

LIMITATION OF LIABILITY & ACKNOWLEDGMENT

FOR PEPTIDE, HORMONE, METABOLIC & RELATED THERAPIES**

 
Provider:

NJ Weight Loss & Preventive Care Clinics PA

(“NJ Weight Loss”)

1. Nature and Scope of Treatment
I understand that I am seeking or electing to receive one or more medical therapies which may include, but are not limited to:

Tesamorelin, IGF-1 (LR3), BPC-157, Ipamorelin, TB-500, L-Glutathione, Sermorelin, Melanotan II, MOTS-c, NAD+, Retatrutide, Semaglutide, Tirzepatide, SLU-PP-332, MK-677 (Ibutamoren), and/or CJC-1295 (collectively, “Therapies”).

I acknowledge that these Therapies may be FDA-approved, used off-label, compounded, investigational, or not FDA-approved for the intended use, and that long-term safety data may be limited or unavailable.

2. New Jersey Standard of Care & Professional Judgment

 I understand that under New Jersey law and regulations (including N.J.A.C. Title 13), licensed physicians may utilize their professional medical judgment to recommend therapies, including off-label use, when deemed medically appropriate.

 I acknowledge that:

• The practice of medicine is not an exact science

• No specific outcome has been promised or implied

• Treatment decisions are individualized and based on clinical judgment, available data, and patient preference

3. Informed Consent – NJ Compliance

I affirm that I have been informed of:

• The nature and purpose of the proposed treatment

• Reasonably foreseeable risks and potential benefits

• Alternatives, including no treatment

 I understand that I may refuse or discontinue treatment at any time.

 4. Primary Medical Doctor (PMD) Reliance Disclaimer

 I expressly acknowledge and agree that:

• I have consulted, or have had the opportunity to consult, with my Primary Medical Doctor (PMD) regarding these Therapies

• I am not relying on any representations, assurances, or opinions made by NJ Weight Loss, its staff, management, owners, contractors, or affiliates

• NJ Weight Loss does not function as my primary care provider and does not replace comprehensive primary medical care

5. Compounded Medication Disclosure (New Jersey)

I understand that:

• Certain medications may be obtained from FDA-registered and/or state-licensed compounding pharmacies

• Compounded medications are not FDA-approved

• Variations in formulation, strength, or bioavailability may occur

• Compounding is legally permissible under New Jersey law when prescribed for an individual patient

6. Investigational & Limited-Data Therapies

 I acknowledge that some Therapies:

• Lack large-scale human clinical trials

• Are supported by emerging, preclinical, or limited clinical data

• May present unknown, unanticipated, or long-term risks

I knowingly and voluntarily accept all known and unknown risks, including risks not yet identified by medical science.

7. Potential Benefits & Risks (Non-Exhaustive)

 I understand that potential benefits are not guaranteed and may include metabolic, body composition, recovery, or symptomatic effects.

I further acknowledge the following known and theoretical risks, which vary by agent:

 Growth Hormone–Related & Peptide Therapies

 (Tesamorelin, Ipamorelin, Sermorelin, CJC-1295, MK-677, IGF-1 LR3)

• Edema, joint or muscle pain

• Headache, dizziness, flushing

• Insulin resistance or altered glucose metabolism

• Hormonal axis suppression

• Theoretical cancer-related risks due to growth signaling

 Tissue Repair / Regenerative Peptides

 (BPC-157, TB-500)

• Limited human safety data

• Unknown angiogenic or systemic effects

• Long-term risks not established

 Metabolic & Mitochondrial Agents

 (MOTS-c, NAD+, SLU-PP-332)

• Extremely limited human data

• Cardiovascular, neurologic, or metabolic effects unknown

• Infusion-related reactions (for NAD+)

 Pigmentation & Appetite-Affecting Agents

 (Melanotan II)

• Nausea, blood pressure changes

• Darkening of existing moles

• Possible increased melanoma risk

• Sexual or neuropsychiatric side effects

 GLP-1 / GIP-Based Agents

 (Semaglutide, Tirzepatide, Retatrutide)

• Nausea, vomiting, diarrhea, constipation

• Gastroparesis

• Gallbladder disease

• Pancreatitis

• Thyroid C-cell tumor risk observed in animal studies

 8. No Insurance / Self-Pay Acknowledgment

 I acknowledge and agree that:

• NJ Weight Loss does not accept or bill insurance, Medicare, Medicaid, or third-party payors

• All services are self-pay

• Pricing has been agreed upon in advance

• I remain financially responsible regardless of outcome

 9. Assumption of Risk & Limitation of Liability (NJ)

 To the fullest extent permitted by New Jersey law, I:

• Voluntarily assume all risks associated with treatment

• Release, indemnify, and hold harmless NJ Weight Loss and its physicians, staff, owners, and affiliates from claims arising out of treatment

Nothing herein shall be construed to waive liability for gross negligence or willful misconduct, to the extent such waiver is prohibited under New Jersey law.

10. Confidentiality, Non-Disclosure & Injunctive Relief

 I acknowledge that NJ Weight Loss’s:

• Pricing structures

• Protocols

• Business practices

 constitute confidential and proprietary information.

I agree that breach of confidentiality may cause irreparable harm and that NJ Weight Loss is entitled to injunctive relief without the necessity of posting bond, to the extent permitted by New Jersey law.

11. Arbitration, Governing Law & Venue

 I acknowledge that:

• All disputes are subject to a separate binding arbitration agreement

• Arbitration is governed by the Federal Arbitration Act and New Jersey law

• Governing law and venue shall be State of New Jersey, unless otherwise stated in the arbitration agreement

12. Severability (New Jersey)

If any provision is deemed unenforceable:

• The remaining provisions shall remain in full force and effect

• The provision shall be modified to the minimum extent necessary to comply with New Jersey law

13. Patient Certification

 By signing below, I certify that:

• I have read and understand this document

• I had the opportunity to ask questions

• I am signing voluntarily

• I understand this agreement is governed by New Jersey law