Z Medi Clinics and Z Medi Spa
CONSENT TO APPETITE SUPPRESSANT USE AND PROGRAM COMPLIANCE IN WEIGHT LOSS PATIENTS
Purpose: Coincidentally to your schedule weight program appointments, you may be prescribed appetite suppressants. To increase your metabolism, you may be given a choice to accept injectable shots of Mic (Methionine/Inositol/Choline) Lipo, Lipo-B, Lipo-C, or other forms of Vitamin B-12 (Cyanocobalamin).
Inclusion Criteria: Please advise your healthcare practitioner of any known health problems and whether you are pregnant or may become pregnant.
Risks: Risks of treatment with appetite suppressants include dry mouth, constipation, insomnia, irritability, headaches, blurred vision, dizziness, mood swings, increased heart rate, and increased blood pressure. In the event of these or similar problems, contact us for medical care to correct the problem.
Benefits: Appetite suppressant use is intended to accelerate your weight loss and make the weight loss program more tolerable.
Alternative treatments: Alternative treatments to this weight loss treatment may include exercise, modified behavioral/lifestyle/diet changes and/or bariatric surgery (depending on extent of obesity).
Voluntary participation: This treatment is voluntary. Refusal to participate will involve no penalty or loss of benefits to which you are otherwise entitled, and you may discontinue participation at any time without penalty or loss of benefits to which you are otherwise entitled.
Consent to treatment by a physician extender: You may be evaluated and treated by a physician assistant (P.A.) or a nurse practitioner (N.P.) whose recommended care and treatment is subject to supervision and review by a licensed physician.
Confidentiality: Your participation and record will be kept completely confidential. Medical records may be reviewed by the Food and Drug Administration; however, confidentiality will still be maintained by redaction of specific patient identifiers.