Weight Loss Program Consent
Dr. Cherkassky's Weight Loss Program Consent:
1.) I hereby authorize and direct Dr. Cherkassky, and such assistants as may be selected by him to administer and treat me, or my relationship to the patient. I consent to be treated with Dr. Cherkassky’s Weight Loss Program described in the attached statement of information and/or a modified program thereof. I understand that my treatment may involve, but not be limited to, the use of appetite suppressant for more than 12 weeks and when directed in higher doses than the dose indicated in the appetite suppressant labeling.
2. I understand the following:
a. The condition for which I am treaded is obesity.
b. Obesity is associated with increased health risk including: high blood pressure, heart disease, stroke, diabetes, arthritis, various forms of cancer and sudden death.
c. Obesity can sometimes be successfully treated with dietary restriction, exercise, and behavioral modification alone…at minimal or no risk.
d. Studies show that people who take appetite suppressants lose more weight over a period of time than people who do not.
e. Studies show that more people are successful at reaching various weight loss goals (e.g., 10% or 20% of starting weight) when taking appetite suppressants.
f. All medications have potential side effects.
g. Side effects of appetite suppressants are usually mild and disappear with time or cessation of treatment.
h. The most common side effects of appetite suppressants include: nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, psychological problems, medication allergies, high blood pressure, rapid or irregular heart beat, and angina. If I notice any of the above symptoms, I would immediately discontinue the appetite suppressants, and contact Dr. Michael Cherkassky's office or my family physician.
We have provided you with the most common side effects. When you get your medication, ask the pharmacy to give you the “Drug Monograph”, which describes all the side effects of the medication. Study and call us if you have any questions.
i. The health care providers treating me will consider the information in the PDR and package inserts, but will also rely on…personal experience, the experience of colleagues, recent longer-term studies, recommendations of university based investigators, journal articles, books, medical lectures, and other sources as well.
j. Many sources have indicated that long term use of the appetite suppressants can be safe and effective and may be necessary in some cases for long-term weight management even though such use has not been systematically studied.
k. I have the right, responsibility, and opportunity to have any questions about treatment with appetite suppressants answered by my health care provider before beginning to take them.
l. Weight loss with the use of medications is unlikely to be permanent unless accompanied by diet, exercise, and other lifestyle changes. Therefore, the medications are being used only as one part of a program including those elements.
m. There are no guarantees…I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I also understand that I will have to continue watching my weight all of my life if I am to be successful.
n. I understand that I am free to discontinue participation in the program at any time, either verbally or in writing without fear or prejudice in order for other treatment that I may receive from Dr. Cherkassky.
o. I understand that this consent extends to the original period of participation in the program and any other periods of participation
p. I understand that should the results of my present treatment or any aspect of it be published in medical scientific journals, all possible precautions will be taken to protect my anonymity.
I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained or any questions I have concerning them have not been answered to my complete satisfaction. I have been urged to take all the time I need in reading and understanding this form and in talking with my health care provider regarding risks associated with the proposed treatment and/or other treatments not involving the appetite suppressants.
Important: if you have any questions as to the risk or hazards of the proposed treatment, or any questions whatsoever concerning the proposed treatment or other possible treatments, ask your provider before signing.
PROVIDER DECLARATION: I have explained the contents of this document to the patient and have answered all the patient’s related questions, and to the best of my knowledge believe the patient has been adequately informed concerning the benefits and risk associated with the use of the appetite suppressants, the benefits and risks associated with alternative therapies, and the risk of continuing in an overweight state. After being adequately informed, the patient has consented to therapy involving appetite suppressants as stated.