Cardiovascular (heart or blood pressure): These problems may include heart palpitations, irregular beats, or rapid heartbeat. These effects are usually mild but can results in serious problems including hear attack or stroke. Also, there medications may increase blood pressure, which if left untreated can lead to heart attack or stroke. If you discontinue the weight loss medication, the elevated blood pressure usually resolves. For this reason, if you are on blood pressure medications you are required to monitory your blood pressure daily and discontinue medications if blood pressure rises, your heart rate increases or you feel palpitations.

Sudden Death: Patients with morbid obesity, particularly those with hypertension, heart disease, or diabetes, have a statistically higher chance of suffering sudden death when compared to normal weight people without such medical problems. Rare instances of sudden death have occurred while obese patients are undergoing medically supervised weight reduction, though no cause and effect relationship with the diet has been established. The possibility cannot be excluded that some undefined or unknown factor in the treatment program could increase this risk in an already medically vulnerable patient.

Reduced Potassium Levels: The calorie level you will be consuming is 1000 or more calories per day and it is important that you consume the calories which have been prescribed in your diet to minimize side effects. Failure to consume all of the food and fluids, nutritional supplements or taking a diuretic medication (water pill) may cause low blood potassium levels or deficiencies in other nutrients. Low potassium levels can cause serious heart irregularities. When someone has been on a reduced calorie diet, a rapid increase in calorie intake, especially overeating or binge-eating, can be associated with bloating, fluid retention, disturbances in electrolytes, or gallbladder attacks and abdominal pain. For these reasons, following the diet carefully and following the gradual increase in calories after weight loss is essential.

Gall Bladder Disease: Any program resulting in rapid weight loss may precipitated the formation of gallstones, which could lead to cholecystitis (inflammation of our gallbladder), which is a medical urgency or emergency and could require surgery. this is typically because of the rapid weight loss, no the medication you are taking. Symptoms include right upper abdominal pain, abdominal pain just below your ribs, nausea, and vomiting.

Pancreatitis: Pancreatitis, or an infection in the bile ducts, may be caused by gallstones or the development of sludge or obstruction in the bile ducts. The symptoms of pancreatitis include pain in the left upper abdominal area, nausea, and fever. Pancreatitis include pain in the left upper abdominal area, nausea, and fever. Pancreatitis may be precipitated by binge-eating or consuming a large meal after a period of dieting. Also associated with pancreatitis is long-term abuse of alcohol and the use of certain medication and increased age. Pancreatitis may require surgery and may be associated with more serious complications and death.

Psychiatric: There are reported cases of "hysterical or psychotic reactions" associated with the use or discontinuation of some of the drugs utilized for weight loss purposes. These reaction are extremely rare.

Men over 40 and post-menopausal women in general, and patients with risk factors for cardiovascular disease should have a cardiovascular evaluation before entering a medically managed weight loss program. This may include an ECG, a stress test, or other testing procedures, as per the discretion of a cardiologist. IF you are over the age of 40, post-menopausal (female), smoke, have a history of high blood pressure, high cholesterol, or you are diabetic, you acknowledge that you have had a cardiac evaluation and that you have been cleared medically prior to starting this weight loss program.
Common, but troublesome side effects may include but not be limited to dry mouth, palpitations, "speedy" feeling, headaches, sleeplessness, rash, fever, nausea, vomiting, allergic reactions, decreased insulin sensitivity, flushing, fatigue, lightheadedness, abdominal cramping, joint pain, fluid retention, and additional side effects not listed that will be discussed during your evaluation with our medical providers. These side effects are generally rare, and most patients tolerate treatment without an issue.
Drug interactions may occur if other medications are taken. Therefore I will check with my prescribing medical provider before starting the program if I am taking other medications.
Certain medical conditions may be worsened if on this program, including glaucoma, hypertension, and heart disease.
Pregnancy (females only). If you become pregnant, inform your physician immediately. Your diet must be changed promptly to avoid further weight loss because a restricted diet could be damaging for a developing fetus. You must take precautions to avoid becoming pregnant during the course of weight loss.

The use of medications for weight management is indicated for those patients who have a BMI of 30 or higher or a BMI of 27 or higher with other medical conditions such as high blood pressure, diabetes, or high cholesterol. Prescribing medications for patients no fitting these criteria, is considered "off label" and no
"FDA approved." Therefore, the potential risks vs. benefits may be great. For patients not fitting the BMI criteria for use of appetite suppression medication you are acknowledging that :
• You have put forth a true effort to lose weight through diet and exercise over the past 6 months and have still not achieved your weight loss goals
• That your inability to lose weight is causing significant emotional distress
• You are choosing to or may be choosing to enter this medically managed weight loss program voluntarily and hold harmless Weight Loss Injection Experts, A Weight Loss Advocates LLC, company and its Medical Providers, for use of such medications.

You acknowledge that alcohol and illicit drug use is prohibited in the program. Drugs like cocaine and amphetamines when used in conjunction with appetite suppressants and other medications prescribed could cause serious injury or death. The use of alcohol will also affect your results.

I understand that my provider and I will determine what my daily caloric intake will be at my initial telemed consultation.

I acknowledge that I understand the amount of weight loss varies from patient to patient, and is, to a large extent dependent on each patients personal motivation and commitment to their diet and exercise plan. No claims as to the efficacy or specific amount of weight loss is either expressed or implied. I understand the importance of routinely following up with Weight Loss Injection Experts, A Weight Loss Advocates LLC, Company and their Medical Providers to monitor my progress during treatment. I understand this is vital to the safety of the treatment program and certify that I will be returning for my follow up appointments as prescribed.

I herby authorize Weight Loss Injection Experts, A Weight Loss Advocates LLC, Company, and its Medical Providers to evaluate me for admission into Weight Loss Injection experts weight management program and treat me accordingly. I consent to obtaining blood work before treatment if deemed necessary. I certify that I am signing this under my own free will and am competent to make my own medical decisions.

I have reviewed the mentioned risks and have determined the benefits outweigh the possible risks associated with medically managed weight loss therapy with Weight Loss Injection Experts. I release any claim in court or any type of complaint that could result from treatment with Weight Loss Injection Experts, A Weight Loss Advocates LLC, company, and its Medical Providers and will no hold liable any provider or staff of Weight Loss Injection Experts, A Weight Loss Advocates LLC, company, and its Medical Providers.

I understand that treatment modalities utilized by Weight Loss Injection Experts, A Weight Loss Advocates LLC, company, and its Medical Providers might not be supported by scientific/medical literature and could be seen as experimental or based off anecdotal claims. Many medical providers, including endocrinologists, surgeons, family practice doctors, etc., might see these types of treatments as not medically necessary. I also understand that many of the medications being utilized within Weight Loss Injection Experts, A Weight Loss Advocates LLC company, and its Medical Providers medically managed weight loss program are considered to be used "off label" and might not be FDA approved for weight loss purposes.

By signing this Health Intake, Medical Consent and Acknowledgment Form, I acknowledge that I have had or will have an opportunity to discuss any concerns and the above information with Weight Loss Injection Experts, A Weight Loss Advocates LLC, company, and its Medical Providers, either in person or by telephone conversation. I consent to the treatment being offered to me by Weight Loss Injection Experts, A Weight Loss Advocates LLC, company, and its Medical Providers and I am satisfied with the explanation. I acknowledge that I have read or have had read to me the above consent and understand the information presented.

Services must be paid for before the time of service.

Health insurance typically does not cover services provided with Weight Loss Injection Experts. If you want to seek insurance reimbursement, we would be happy to provide you itemized invoices that you can submit to your insurance company.

Weight Loss and or Wellness Injections are considered a controlled substance. I agree that I will take my medications as prescribed. I agree to follow my medical providers instructions. I also agree that I will not sell or share my prescriptions to other individuals

I understand that treatments used with Weight Loss Injection Experts might not be considered a medical necessity. Treatments rendered are for the purpose of improving your quality of life through weight loss, hormone restoration, nutritional and supplemental counseling, and weight loss treatment.

I agree that if I am having any side effects or become sick, that I will follow up with my primary care provider or to to an urgent care or emergency department.

I acknowledge that Weight Loss Injection Experts, A Weight Loss Advocates LLC, company, and the Health Care Provider I meet with are not my primary care provider unless I elect them so. I agree that I will continue with routine care through my primary care provider and notify them of treatments prescribes with Weight Loss Injection Experts, A Weight Loss Advocates LLC, company.

I understand that there are no refunds for services or products rendered. We cannot accept back used medications once they have been dispensed per state regulation.

I understand that having an appointment with Weight Loss Injection Experts, A Weight Loss Advocates LLC, company, does not necessarily entitle me to being issued a prescription for hormone replacement, weight loss medication or additional medications. Every individual is different, and it is that the medical providers discretion to issue a prescription.

I understand that I must maintain my follow-up appointments to remain on treatment. It is important that lab work is monitored regularly for safety purposes. It is important for the medical provider who manages my treatment and it is at their discretion to provide labs, medications, supplements counseling, hormones or GLP-1 drugs.

I acknowledge that I have been or will be advised of the risks and benefits of treatment. I also acknowledge that I have been or will be advised of possible complications and side effects. I understand the risks, benefits, complications and side effects of treatment.

I am voluntarily requesting treatment with Weight Loss Injection Experts, A Weight Loss Advocates LLC, company, and their Health Care Providers in regards to weight loss therapy as determined by a mutual decision between myself and the medical provider even if my hormone levels are considered to be in normal range for my age based off of other medical society recommendations and guidelines or if I am just considered overweight not obese.

I do not hold any medical practitioner of Weight Loss Injection Experts, A Weight Loss Advocates LLC, company, responsible for performing weight loss, wellness and or age-related preventive care. I agree that I will follow-up with my primary care provider to obtain these screenings and I hold Weight Loss Injection Experts, A Weight Loss Advocates LLC, company, and its Health Care Providers harmless if an adverse event occurs during my treatment. I will ensure that my primary care provider provides the results of such screenings to Weight Loss Injection Experts, A Weight Loss Advocates LLC, company, and the Health Care Provider assigned to me as this could change the treatment prescribed to me .

Any questions I have regarding this treatment have been answered or I will get them answered to my satisfaction. I understand that I will be responsible for administering the medications prescribed to me if I do not have them administered to me. I also promise to comply with the dosages and frequency of medications prescribed to me.
I certify that I am under the regular care of a primary care provider for any other conditions I might have or am found to have. I will consult with my PCP or specialist regarding any other condition I might have. I understand that if I do not have a primary care provider, that I will be encouraged to seek one out. I acknowledge that I am seeking care at Weight Loss Injection Experts, A Weight Loss Advocates LLC, company, and its Health Care Providers for medically managed weight loss services that Weight Loss Injection Experts, A Weight Loss Advocates LLC, company, and its Health Care Providers offers. I acknowledge I am not wanting to establish primary care with Weight Loss Injection Experts, A Weight Loss Advocates LLC, company, and its Health Care Providers and I am here for specialized care including weight loss therapy, diet counseling, exercising counseling, hormone counseling, etc.

There is a risk of regaining the weight you have lost. Obesity is a chronic condition, and the majority of overweight individuals who lose weight have a tendency to regain all or some of it back over time. Factors which favor maintaining weight loss include exercise, adherence to a diet that is a low-calorie, nutritious, and full of lean proteins and vegetables, and planning a strategy for coping with weight regain before it occurs. Successful treatment may take months or even years. Utilizing medications to assist you in your weight loss goals in addition to diet and exercise could result in the weight coming back if you do not maintain eating a healthy diet and exercising. Additionally, if you have had fluctuations in your weight in the past, it may be more difficult to maintain the weight you lose.

I, agree to indemnify, defend, protect, and hold harmless the medical providers with Weight Loss Injection Experts, A Weight Loss Advocates LLC, company, and its Health Care Providers; and their respective officers, directors, employees, stockholders, assigns, successors and affiliates (Indemnified Parties) from, against and in respect of all liabilities, losses, claims, damages, judgments, settlement payments, deficiencies, penalties, fines, interest and costs, expenses suffered, sustained, incurred or paid by the indemnified parties, in connection with, results from or arising from directly or indirectly the medical providers withWeight Loss Injection Experts, A Weight Loss Advocates LLC, company, and its Health Care Providers, rendering medical care, services, advice and/or treatment, my failure to disclose all relevant information regarding my medical and physical condition, acts or omissions, the medical providers with Weight Loss Injection Experts, A Weight Loss Advocates LLC, company, and its Health Care Providers. I am aware of the potential side effects associated with weight loss therapy, accept all the risks involved in taking the medication and will not seek indemnification or damages from the indemnified parties.