Medical Weight Loss Consent Form

Patient's First Name

Patient's Last Name

Date of birth

Phone Number

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Please provide information on any existing medical conditions, allergies, or medications.

Weight Loss Program Information:

Program Overview: I understand that I am participating in a medical weight loss program that may include dietary guidance, exercise recommendations, and/or medical interventions.

Risks and Benefits: I have been informed of the potential risks and benefits associated with the weight loss program, including but not limited to changes in health, metabolism, and lifestyle.

Medical Monitoring: I understand that my progress will be monitored, and adjustments to the program may be made based on my health status and weight loss goals.

Risk of medication use:I have been informed and fully understand the minor risks associated with GLP1 Medication such as severe constipation, bloating, abdominal cramping, nausea, vomiting, fatigue, site reactions, headache, and nasopharyngitis, and I have been informed regarding the Major Risks such as pacreatitis, thyroid tumors, bowel blockages, and death. I also understand that medication is used at my own risk and Healthworx Family Clinic s-corp does not assume any responsibility for any such reactions to these medications. I also understand by signing this document that the medication may not result in weight loss and you may need to change medication or increase doseages. Healthworx Family Clinic does not guarantee weight loss while using the medication, and you understand that calorie reduction and exercise, full lifestyle change is the only way to see best results.

TELEMEDICINE CONSENT:

I consent to a telemedicine appointment where I will be providing my own information such as weight, height, and other vital signs if applicable, and I understand that some information may not be available to Healthworx Family Clinic at the time of the online appointment. I understand that it is my responsibility to provide information to Healthworx Family Clinic regarding all medications that I am currently taking and all diseases that I have been diagnosed with and have in the past or are seeing a Doctor for currently, Healthworx Family Clinic is not responsible for any information that is withheld at the time of the appointment. Based on your medical history and answers in the interview, you may be required to be cleared by certain specialists before you may begin the program. The fee today is non refundable, however if you are cleared as requested you will not be required to pay for another appointment to get your first months medication if you are cleared within the first 60 days of the appointment. Any clearance after 60 davs will reguire a new appointment and you will be charged the regular fee of 100.00

Informed Consent:

Informed Consent: I have had the opportunity to ask questions about the weight loss program, and my questions have been answered to my satisfaction.

Voluntary Participation: I understand that my participation in the weight loss program is voluntary, and I may choose to discontinue at any time.

Confidentiality: I acknowledge that my health information will be kept confidential, except as required by law.

Release of Information: I authorize the release of relevant medical information to healthcare professionals involved in my weight loss program.

Payment and Fees:

Fees: I understand the fees associated with the weight loss program and agree to fulfill my financial obligations.

I have read and understood the information provided in this Medical Weight Loss Consent Form. I voluntarily consent to participate in the weight loss program.

Patient's Signature

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

First Name

Last Name

Date Signed

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Witness Signature (if applicable)

Date Signed

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