Medical Intake Form

I authorize Laser Me and its staff to assist me with medical weight reduction. This program will include reducing caloric intake, regular exercise, and behavioral lifestyle changes. My treatment may consist of appetite suppressants and using medical injections. I further understand that to continue this program, I must have regular follow up and show continued weight loss.

As with any prescription medication, I understand the potential risks regarding appetite suppressants and medical injections involved. Side effects may include nervousness, constipation, insomnia, headaches, dry mouth, weakness, fatigue, medication allergy, increased blood pressure, and irregular heart rate. I understand that these and other risks could be severe or, in rare cases, life-threatening.

I understand that if I develop side effects from the medication, I will discontinue taking the medication and notify the Laser Me staff immediately. If the problem is severe, I will go to the nearest Emergency room for immediate care.

I do not have a history of alcohol abuse, drug abuse, schizophrenia, manic-depressive illness, or eating disorder since these conditions constitute a contraindication to using appetite suppressants.

I agree not to take weight loss medications other than those prescribed by Laser Me and further agree to inform the staff of ANY changes in my medication or medical history.

I can be successful without using appetite suppressants or injections as long as I follow a reduced-calorie nutrition plan and increase my activity level. However, such medications and injections may significantly help my weight loss progress.

I understand the risks associated with being overweight or obese include the possibility of high blood pressure, diabetes, heart disease, stroke, cancer, arthritis and pain of the joints, gallbladder disease, and even sudden death.

I understand there is no guarantee that this program will work for me.

I understand that I must follow the program as directed to achieve my desired weightloss.

I understand that my insurance does not cover these charges and that Laser Me does not provide or fill out claim forms for insurance purposes.

By consenting to treatment, I agree to pay, in total, for all visits and charges incurred at each visit.

I understand that a 24-hour cancellation policy is strictly enforced and that should I cancel or miss my appointment in less than 24 hours, my authorized credit card will be charged $75 for a missed appointment.

By agreeing to this statement, I hereby authorize Laser Me to charge my credit card in the event of late cancellations (less than 24 hours) or missed appointments.

By signing below, I affirm that I have read and comprehended this consent form in its entirety and understand all potential risks and benefits linked to my treatment for weight loss.