I _______________________ authorize the designess of the Comprehensive Medical Weight Loss Solutions to help me in my weight reduction efforts. I understand that my program will consist of a nutritional plan, regular physical activity, instruction in behavior modification techniques, and may involve the use of medications. Other treatment options may include a very low-calorie diet, or a protein supplemented diet. I further understand that if appetite suppressants are used, they may be used for durations exceeding those recommended in the medication package insert. It has been explained to me that these medications have been used safely and successfully in private medical practices 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 remaining overweight or obese. Risks of this program may include but are not limited to nervousness, sleeplessness, headaches, dry mouth, gastrointestinal disturbances, weakness, tiredness, psychological problems, high blood pressure, rapid heartbeat and heart irregularities. These and other possible risks could on occasion be serious or even fatal. Risks associated with remaining overweight are tendencies to 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.
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 obesity may be a chronic lifelong condition that may require changes in eating habits and permanent changes in behavior to be treated successfully.
I contract, through this consent, to follow up monthly, in the office for ongoing assessment. I will not request any medications refills pertaining to my weight loss prescription unless I am being seen in the office or via telemedicine for this purpose. I also contract to follow up as instructed with counselling if this is part of my treatment plan.
I have read and fully understand this consent form and all items have been explained to me. My questions have been answered to my complete satisfaction.