Medical Weight Loss Consent Form
Prior to treatment, I have fully disclosed any medical conditions or diseases. If I fail to disclose any medical condition that I have, I release the doctor and facility from any liability associated with this procedure.
I agree to immediately report any problems that might occur to my medical provider during the treatment program. I further understand that not complying with the dosage recommendations and dietary restrictions could increase risks. If I do not follow these recommendations and restrictions, I agree to release the doctor and facility from any liability arising as a result of this. While adverse side effects or complications are not expected, in the event that an illness does occur, I understand that I need to contact Mia Hartman FNP-C immediately. If I experience an emergency situation, I understand that I need to go to an emergency facility.
I understand that if there are any changes in my medical history or there are any changes in my medications or any other changes relevant to this procedure, I will advise the doctor at that time.
I give permission for photographs of the treated area(s) to be kept in my file, and to be used for teaching purposes, and/or promotional purposes. complete patient confidentiality will be maintained at all times.
I understand that I can be successful without the use of appetite suppressants or injections as long as I am following a reduced calorie nutrition plan and increasing my activity level, however the use of such medications and injections may significantly help with my weight loss progress.
I understand that there is no guarantee that this program will work for me. I understand that I must follow the program as directed in order to achieve weight loss.
By consenting to treatment, I agree to pay, in full, for all visits and charges incurred at each visit. I understand that these charges are not covered by my insurance and Optimal You, LLC does not provide or fill out claim forms for insurance purposes.
I have read and fully understand the above terms. All my questions have been addressed to my satisfaction. I agree to release the provider and the facility from any liability associated with this treatment.
By checking this box, I agree to use electronic records and signatures and I acknowledge that I have read the related consumer disclosure.
I am the parent/guardian of this patient
