Informed Consent for Weight Management Treatment & Appetite Suppressants Voluntary Enrollment
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- Lorena Lamb
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1 Informed Consent for Weight Management Treatment & Appetite Suppressants Voluntary Enrollment I am voluntarily enrolling in an aggressive weight management program. I hereby authorize Dr. Britton and his staff to provide medical care for me to achieve the goals of weight loss and weight maintenance. Such care may include but is not limited to obtaining a complete medical and weight history, a physical examination, appropriate laboratory screening, follow-up visits as per the clinic recommendations, direct phone calls, psychological therapy, nutritional counseling, fitness counseling, vitamin supplementation, and possibly the use of appetitesuppressant prescription medication. Program Purpose and Risks of Obesity The purpose of enrollment in the program is for the benefit of my overall health and to lose weight. Obesity and being overweight increases my risk for developing heart disease, diabetes, stroke, cancer, and many other diseases. It also reduces my overall life expectancy. I recognize these current risks to my health as unacceptable and wish to aggressively treat my weight by enrolling in this program. No Guarantees I understand that no guarantee or representation has been made or given to me by anyone as to the results or outcomes of this weight management program. I understand that a major part of the success of the program will depend upon my own personal efforts in following the advice and recommendations I have received as a program participant. Risks of the Program I understand that there are risks to me in choosing to enroll in this program. These risks include but are not limited to the following: 1) Physical injury (from such things like increased exercise and activity modification). 2) Worsening of chronic disease and/or malnutrition. 3) Cardiac effects (from use of weight loss medication, if used, including elevated blood pressure, rapid pulse, heart irregularities, heart attack, and stroke). 4) Gastrointestinal side effects (from the use of dietary fiber supplement and calcium including possible constipation, diarrhea, and/or bloating). 5) Fatigue. 6) Nervousness, sleeplessness, anxiety, headaches, and dry mouth. 7) Rare but more serious complications include primary pulmonary hypertension and heart valve disease. 8) An allergic reaction to a medication 9) I understand that regular follow-up visits and evaluations allows for early detection and management of these possible problems.
2 General Comments I understand that the use of appetite suppressants is part of a comprehensive weight management program and that the medications themselves will not make me lose weight. I understand that to continue to receive appetite suppressants that I must continue to lose weight and continue to make my appointments as scheduled. I understand that in consenting for treatment I agree to pay in full for all visits and charges at the time of each visit. I understand that there are no refunds given at any time for any reason. Off Label use of Medications Dr. Britton and Lindsay De Stefano PA-C supports the off-label use of medications and may do this from time to time as a part of the program in which I am enrolled. Dr. Britton and/or Lindsay De Stefano PA- C will inform me whenever this is to happen. Off-label use of medications is a common medical practice and is often specifically used in weight management programs and will be used when scientific studies have proven the specific treatment to be effective. Insurance Billing Health insurance companies do not pay for programs such as this one. I understand that I am personally responsible for payment of all services rendered at this facility for weight management. We do not bill any insurance company for any service rendered at this clinic. We will provide you with a receipt that includes the diagnosis code and charges recorded if you wish to attempt to obtain reimbursement for services rendered on your own. Signature Attestation By signing this document below, I certify that I have read and fully understand this consent form. The risks and benefits of enrolling in this program have been explained to me and all my questions answered. I have read and understand The Weight-Loss Consumer Bill of Rights which is attached to this document. I attest that I do not have any history of drug or alcohol abuse, schizophrenia, or bipolar illness as these conditions preclude the use of appetite suppressants. I agree not to take any appetite suppressants or other medications for weight management than those prescribed by Dr. Britton and/or Lindsay De Stefano PA- C unless specific permission has been given to me by Dr. Britton and/or Lindsay De Stefano PA-C to do so. Additionally, I agree to inform Dr. Britton and/or Lindsay De Stefano PA-C of any changes in medications made by other practitioners I may see, or changes in my general health. YOUR SIGNATURE BELOW INDICATES YOUR CONSENT TO TREATMENT AND YOUR UNDERSTANDING OF THE STATEMENTS AS MADE ABOVE. IF YOU HAVE ANY QUESTIONS WHATSOEVER CONCERNING THE RISKS, PROPOSED TREATMENT, OR ANY OTHER ISSUE WITH THIS PROGRAM, PLEASE ASK DR BRITTON OR LINDSAY DE STEFANO PA-C BEFORE SIGNING THIS FORM. Signature DATE
3 WEIGHT-LOSS CONSUMER BILL OF RIGHTS A) WARNING: RAPID WEIGHT LOSS MAY CAUSE SERIOUS HEALTH PROBLEMS. RAPID WEIGHT LOSS IS WEIGHT LOSS OF MORE THAN 1 1/2 POUNDS TO 2 POUNDS PER WEEK OR WEIGHT LOSS OF MORE THAN 1 PERCENT OF BODY WEIGHT PER WEEK AFTER THE SECOND WEEK OF PARTICIPATION IN A WEIGHT-LOSS PROGRAM. B) CONSULT YOUR PERSONAL PHYSICIAN BEFORE STARTING ANY WEIGHT LOSS PROGRAM. C) ONLY PERMANENT LIFESTYLE CHANGES, SUCH AS MAKING HEALTHFUL FOOD CHOICES AND INCREASING PHYSICAL ACTIVITY, PROMOTE LONG TERM WEIGHT LOSS. D) QUALIFICATIONS OF THIS PROVIDER ARE AVAILABLE UPON REQUEST. E) YOU HAVE A RIGHT TO: 1) ASK QUESTIONS ABOUT THE POTENTIAL HEALTH RISKS OF THIS PROGRAM AND ITS NUTRITIONAL CONTENT, PSYCHOLOGICAL SUPPORT, AND EDUCATIONAL COMPONENTS. 2) RECEIVE AN ITEMIZED STATEMENT OF THE ACTUAL OR ESTIMATED PRICE OF THE WEIGHT-LOSS PROGRAM, INCLUDING EXTRA PRODUCTS, SERVICES, SUPPLEMENTS, EXAMINATIONS, AND LABORATORY TESTS. 3) KNOW THE ACTUAL OR ESTIMATED DURATION OF THE PROGRAM. 4) KNOW THE NAME, ADDRESS, AND QUALIFICATIONS OF THE DIETITIAN OR NUTRITIONIST WHO HAS REVIEWED AND APPROVED THE WEIGHT-LOSS PROGRAM ACCORDING TO S (1) (j), FLORIDA STATUTES I have received, reviewed and understand the Weight Loss Consumer Bill of Rights for the State of Florida. I have asked and received answers to my questions pertaining to the Weight Loss Consumer Bill of Rights and I fully understand my rights as granted by the State of Florida. Signature Date
4 Patient-Clinic Agreement The purpose of this document is to explain how we will partner with our patients to achieve the best possible outcomes for you. What we will do for you: 1) We will arrange appointments for you that are as convenient for you as possible, given your schedule. 2) We will see you as close to your appointment time as possible, given that emergencies do arise with you, other patients and with our staff. 3) We will never double-book appointments and we will give you adequate time with our doctor and staff 4) If you have been referred to us by your regular doctor, we will work in conjunction with him/her and we will send reports to your doctor to keep them informed of what we have done or recommended. 5) We will develop a program of weight management that is best suited to your personal needs. We have guidelines that we follow and we have a great deal of latitude in how we apply them. We do not use canned programs that are designed for every patient to be the same. 6) We will provide a physician assistant guided by a medical doctor who is trained in using our specific program. Our medical staff comes from a wide variety of training and experience backgrounds. 7) The physician assistant and the physician will evaluate your personal situation, perform a number of tests and perform an examination. We will then prescribe exercise, a diet for your weight loss goals, and medicines if needed and indicated. We will follow you with regular office visits until you have met your desired weight loss goals. We will then shift the program to follow you and monitor your progress over time. 8) We do not file your medical insurance for you. Health insurance policies do not cover this sort of program, but we will provide a receipt that you can use if you wish to file a claim on your own. What we expect of you as a patient: 1) We expect you to be on time and keep your appointments. 2) We expect you to pay at the time of service. 3) Missing appointments interferes with your progress so do not miss your appointments. 4) If you cannot make your appointment for any reason, please call us and let us know. If it is after hours, call us and leave us a message. 5) Please turn off your cell phone in the treatment area. Staff and other patients do not appreciate your talking on the phone in the treatment area. 6) Please manage children if you must bring them to the office during your visits. Please keep the kids from climbing all over the furniture as it is a risk to them and to us and it disturbs other patients. We cannot allow children in the treatment area unless they stay close with you during treatment. They are not allowed to run free in the treatment area. 7) Please let us know if you are having any problem with any aspect of our service Signature Date
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