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For Women Only:

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October 21, 2020

Weight Loss Informed Consent

Our commitment to you…

At Physician’s Plan Weight Loss, we work with you to create an individualized plan to achieve your weight loss and health goals. Real results are not only possible; they are sustainable with the right plan. Together with the Physician’s Plan Weight Loss team, we will create a customized plan to help you lose weight, curb your hunger, improve your health and increase your energy. From our weight loss coaches to our clinical providers, every member of the Physician’s Plan Weight Loss team is fully invested in your success.

Your role...

I understand my success will depend upon my commitment to understanding and fulfilling my obligations to the course of treatment Physician’s Plan Weight Loss + Wellness has created for me. It is important that I be willing to:

• Provide honest and complete answers to questions about my health, weight problem, eating activity, lifestyle and behavioral patterns so my Physician’s Plan Weight Loss + Wellness team can develop and support my individualized weight loss plan.

• Devote the time needed to complete and comply with the course of treatment Physician’s Plan Weight Loss + Wellness team has outlined for me, including but not limited to a reduced caloric diet, food journal, weekly weigh-ins, nutritional counseling, Lipo-Plus B-12 vitamin injections, exercise recommendations and maintenance program.

• Make and keep monthly follow-up appointments with my provider and/or any other diagnostic measures which my provider may deem necessary during my course of treatment.

• I will advise the clinic staff of any concerns, problems, complaints, symptoms, questions, and/or changes in medical history. Updated information allows the Physician’s Plan Weight Loss + Wellness team the opportunity to provide the best care possible for my success.

Potential benefits...

Medical benefits:
• Lower blood pressure, reducing the risks of hypertension
• Lower cholesterol, reducing the risks of heart and vascular disease
• Lower blood sugar, reducing the risks of diabetes
• Decreased joint pain

Lifestyle benefits:
• Improved energy
• Improved mood
• Better sleep
• Greater Confidence

Appetite Suppressant

I understand my treatment may involve, but not be limited to, the use of appetite suppressants for more than 12 weeks and when indicated in higher doses than the dose indicated in the appetite suppressant labeling.

I have read and understand the Medical Director’s statements that follow:

• Medications, including the appetite suppressants, have labeling worked out between the makers of the medication and the Food and Drug Administration. This labeling contains, among other things suggestions for using the medication. The appetite suppressant labeling suggestions are generally based on shorter term studies (up to 12 weeks) using the dosages indicated in the labeling.

• As a bariatric physician, I have found the appetite suppressants helpful for periods far in excess of 12 weeks, and at times in larger doses than those suggested in the labeling. As a physician, I am not required to use the medication as the labeling suggests, but I do use the labeling as a source of information along with my own experience, the experience of my colleagues, recent longer term studies and recommendations of university based investigators. Based on these, I have chosen, when indicated, to use the appetite suppressants for longer periods of time and at times, in increased doses.

• Such usage was not studied when the medication underwent initial studies but we have performed post release studies that support long/longer term use in this capacity. It is possible as with most other medications, that there could be serious side effects (as noted below).

• As a bariatric physician, I believe the probability of such side effects is outweighed by the benefit of the appetite suppressant use for longer periods of time and when indicated in increased doses. However, you must decide if you are willing to accept the risks of side effects, even if they might be serious, for the possible help the appetite suppressants use in this manner may give.

I understand it is my responsibility to follow the instructions carefully and to report to a Physician’s Plan provider of any/all medical problem.

I have disclosed all medications I am currently prescribed including but not limited to any controlled substance medications (i.e. pain, anxiety, ADHD, and/or other stimulants) other than those prescribed by my Physician’s Plan provider. And will notify my Physician’s Plan Weight Loss and Wellness practitioner of any changes in my medication.

I understand that the appetite suppressant is a controlled substance and I will not receive a weight loss prescription/s from another prescriber without my Physician’s Plan provider’s knowledge.

I understand that under the state/federal law it is illegal for anyone to obtain, or attempt to obtain, a controlled substance by deceit, misrepresentation, fraud, or concealment of facts. Any misuse of or criminal activity reported can result in potential investigation and/or prosecution by law enforcement, professional licensure, or regulatory agency.

I understand that refills of my prescription will be issued at the time of my monthly follow-up visit with a physician’s Plan provider.

I understand while I am taking this medication my doctor may need to contact other doctors, family members to get information regarding my care and/or use of this medication. I will be asked to sign a release of medical records (ROR).

I understand the purpose of this treatment is to assist me in my desire to decrease my body weight and to maintain my weight loss. I understand my continuing to receive the appetite suppressant will be dependent on my progress in weight reduction and weight maintenance. I understand there are other ways and programs that can assist me in my desire to decrease my body weight and to maintain this weight loss. In particular, a balanced calorie counting program or an exchange eating program without the use of the appetite suppressant would likely prove successful if followed, even though I would probably be hungrier without the appetite suppressants.

Risks of Proposed Treatment:

I understand this authorization is given with the knowledge that the use of the appetite suppressants for more than 12 weeks and in higher doses than the dose indicated in the labeling involves some risks and hazards. The more common include: nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, psychological problems, medication allergies, high blood pressure, and rapid heartbeat and heart irregularities. Less common, but more serious risks are primary pulmonary hypertension and valvular heart disease. These and other possible risks could, on occasion, be serious or fatal.

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.

Patient's Consent:

I, , agree to participate in a telemedicine evaluation. By signing this agreement, I authorize the electronic transmission of my medical information so that it can be viewed by a provider and other persons involved in my weight loss treatment. I hereby give my informed consent to complete my weight loss consultation remotely via phone/video conferencing.

October 21, 2020