DHHH Mobile Weightloss Consent Form

Information and Assignment of Benefits

I, the undersigned, authorize the release of medical information to my primary care physician, referring physician, or consults as needed for my treatment.

I understand that payment is required for all services at the time they are rendered. Please note that Right Weight Clinics will not submit any bills to insurance companies for its services. Instead, Right Weight Clinics will provide a receipt for my visit, but will not complete any insurance-specific forms.

By signing below, I agree to receive promotional messages sent via an auto-dialer. I understand that this agreement is not a condition of any purchase, and standard data rates for SMS apply.

I certify that the information I have provided is accurate and complete. I acknowledge that I have had the opportunity to ask questions regarding this matter. I also permit a copy of this authorization to be used in place of the original.

This authorization may be revoked by me at any time in writing.

WEIGHT LOSS PROGRAM INFORMED CONSENT

By signing below, I acknowledge that I have read and fully understand the details of the weight loss program outlined in this informed consent. I agree to the terms of the program, which may include the following components:

• Balanced calorie-deficit diet
• Vitamins with amino acid complex injections
• Regular exercise program
• Behavior modification techniques
• Use of appetite suppressant medications and Semaglutide

I understand that my program may involve the use of appetite suppressants for durations longer than the typical recommendation found in the medication package insert. I am also aware that, as with any medical treatment, there are associated risks, though there are also significant benefits related to weight loss.

Weight Loss Benefits

I understand that weight loss can improve various obesity-related conditions, including:

• High blood pressure
• High cholesterol
• Sleep apnea
• Arthritis
• Diabetes
• Increased energy levels
• Reduced aches and pains
• Improved mobility and breathing
• Better sleep quality and restfulness
• Prevention of angina and chest pain
• Reduced risk of heart disease, stroke, and sudden death
• Improved blood sugar levels

These benefits are more significant in individuals who are more overweight, though I understand that the associated risks may be modest if I am not significantly overweight.

Risks of Appetite Suppressant Medications

I understand that while appetite suppressants, such as Phentermine, have been safely used by millions of people, there are potential side effects and risks, including but not limited to:

Phentermine Risks

• Common symptoms: Depression, drowsiness, increased blood pressure, irritability
• Less common/rare symptoms: Blurred vision, confusion, diarrhea, dizziness, dry mouth, headache, irregular heartbeat, vomiting, stomach pain, tiredness, heart palpitations, chest pain, shortness of breath
• Potential long-term side effects: Dizziness, hair loss, gall bladder disease, and other medical complications

Semaglutide Risks

• Possible risks: Acute pancreatitis, diabetic retinopathy, hypoglycemia (especially if using insulin), acute kidney injury due to dehydration, hypersensitivity reactions, acute gallbladder disease

I understand that the program provides medical supervision to help minimize these risks.

Program Participation

I understand that much of the success of this program depends on my efforts, and that there are no guarantees or assurances that the program will be successful. I acknowledge that obesity may be a chronic, lifelong condition that requires permanent changes in eating habits and behavior to treat effectively.

Injection-Related Risks

If injections are part of my treatment, I understand that potential risks may include:

• Abscess
• Cellulitis
• Tissue necrosis
• Granuloma
• Muscle fibrosis
• Contractures
• Hematoma
• Injury to blood vessels, bones, and peripheral nerves

Medication Disclosure

I agree to inform my doctor of all prescriptions and over-the-counter medications I am currently taking. I understand that Phentermine should not be used in combination with certain substances, including:

• Cocaine
• Caffeine
• Cold medicines
• Asthma rescue medications
• SSRIs, SNRIs, MAOIs, etc.

I understand that Phentermine is not recommended for use by:

• Children under the age of 17
• Adults over the age of 65
• Pregnant or breastfeeding women
• Individuals with significant health issues (e.g., heart disease, hypertension, kidney disease, psychiatric disorders, etc.)

Phentermine Regulations

I understand that Phentermine is a Schedule IV controlled substance and that there are strict regulations regarding its dispensing. Once prescribed, I will not receive a replacement or refill except in compliance with federal and state guidelines. If I lose my prescription or the medication is disposed of, I understand that I will need to return for an office visit to receive a new prescription. There will be no exceptions to these regulations.

False Positive Drug Test

I acknowledge that Phentermine may cause a false positive on drug tests for amphetamines. Upon request, my physician will provide documentation to confirm that I am prescribed Phentermine.

Medication Storage and Safety

I agree to store all medications, including Phentermine, out of reach of children, in a cool, dry place, away from heat and direct light. I understand that outdated medications should not be used after their expiration date.

Prescription Dispensation

If a prescription for an appetite suppressant is issued, I may choose to fill it at any pharmacy; however, I understand that I can have it filled at Right Weight Clinics LLC for my convenience.

Acknowledgement

By signing below, I acknowledge that I have read and fully understand the information provided in this consent form. I understand that if any part of this form was not explained or if I have any questions, I should ask for clarification before signing.

I confirm that I have been given ample time to read this document and discuss it with my doctor and/or their staff.