I
I, {patientOr} (patient or guardian name), understand and acknowledge that treatment by Beach Medical Weight Loss, LLC, Dr. Melissa Pearce, MD and their designated assistants is limited solely to assistance with weight reduction efforts. This treatment does not provide a substitute or replacement for any regular physician. Beach Medical Weight Loss, LLC and Dr. Melissa Pearce, MD does not treat acute or chronic medical problems, and I agree to see my regular physician for these problems.
II
1. I, {patientOr} (patient or guardian name) authorize Dr. Melissa Pearce, MD and whomever she designates as her assistants to assist me in my weight reduction efforts. I understand my treatment may involve but not be limited to, the use of appetite suppressants for more than 12 weeks and when indicated in higher doses than the dose indicated in the appetite suppressant labeling. I understand that my program may consist of a balanced deficit diet, a regular exercise program, and instructions in behavior modification techniques, and may involve the use of appetite suppressant medications.
2. I have read and understand my doctor’s statements that follow:
“Medications, including the appetite suppressants, have labeling worked out between the makers of the medication and Food and Drug Administration. This labeling contains, among other things, suggestions for using the medication. The appetite suppressant labeling suggestions are generally based on shorter term studies (up to 12 weeks) using the dosages indicated in the labeling.”
“As a physician, I have found the appetite suppressants helpful for periods far in excess of 12 weeks, and at times in larger doses than those suggested in the labeling. As a physician, I am not required to use the medication as the labeling suggests, but I do use the labeling as a source of information along with my own experience, the experience of my colleagues, recent longer term studies and recommendations of university based investigators. Based on these, I have chosen, when indicated, to use the appetite suppressants for longer periods of time and at times, in increased doses.”
“Such usage has not been as systematically studied as that suggested in the labeling and it is possible, as with most other medications, that there could be serious side effects (as noted below).”
“As a physician, I believe the probability of such side effects is outweighed by the benefit of the appetite suppressant use for longer periods of time and when indicated in increased doses. However, you must decide if you are willing to accept the risks of side effects, even if they might be serious, for the possible help the appetite suppressants use in this manner may give.”
3. I understand it is my responsibility to follow the instructions carefully and to report to the doctor treating me for my weight any significant medical problems that I think may be related to my weight control program as soon as reasonably possible.
4. I understand the purpose of this treatment is to assist me in my desire to decrease my body weight and maintain this weight loss. I understand my continuing to receive the appetite suppressant will be dependent on my progress in weight reduction and weight maintenance.
5. I understand there are other ways and programs that can assist me in my desire to decrease my body weight and to maintain this weight loss.
In particular, a balanced calorie counting program or an exchange eating program without the use of the appetite suppressant would likely prove successful if followed, even though I would probably be hungrier without the appetite suppressant.
III.
1. RISKS OF PROPOSED TREATMENT:
I understand this authorization is given with the knowledge that the use of the appetite suppressants for more than twelve weeks and in higher doses than the dose indicated in the labeling involves some risks and hazards. The more common include: nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, psychological problems, medication allergies, high blood pressure, rapid heartbeat and heart irregularities. Less common, but more serious, risks are primary pulmonary hypertension and valvular heart disease. These and other possible risks could, on occasion, be serious or fatal. I understand that if I have questions or concerns about side effects or risks, or if I prefer to see the Medical Director (M.D.) for my evaluation and care, the Medical Director is available by appointment for these purposes.
2. NO GUARANTEE: I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I also understand that I will have to continue watching my weight all my life if I am to be successful in maintaining any weight loss achieved.
3. PATIENT’S CONSENT: I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained, or any questions I have concerning them have not been answered to my complete satisfaction, I have been urged to take all the time I need in reading and understanding this form and in talking with my doctor regarding risks associated with the proposed treatment and regarding other treatments not involving the appetite suppressants. I also understand that participation in this program is strictly voluntary and is my choice to participate or not. I understand that I may discontinue this treatment at any time at my discretion.
4. WARNING:
IF YOU HAVE ANY QUESTION AS TO THE RISKS OR HAZARDS OF THE PROPOSED TREATMENT, OR ANY QUESTIONS WHATSOEVER CONCERNING THE PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK YOUR DOCTOR NOW BEFORE SIGNING THE CONSENT SIGNATURE FORM.
I have read and fully understand this consent form. I realize I should not sign this form if all items have not been explained to me. My questions have been answered to my complete satisfaction. I have been urged and have been given all the time I need to read and understand this form. (If you have any questions regarding the risks or hazards of the proposed treatment, or any questions whatsoever concerning the proposed treatment or other possible treatments, ask your doctor now before signing this consent form.)