authorize DOCTOR’S WELLNESS STUDIO physicians (hereinafter referred to as “physician”) to use dietary and nutritional counseling, behavior modification, exercise counseling, the administration of appetite suppressants and other supplements, to assist me in achieving my weight loss goals.
I agree to follow the instructions of the physicians and their assistants in this program carefully and to report promptly any change in my condition possibly related to the administration of the appetite suppressants.
I understand that the purpose of this program is my long-term weight control, and that other unrelated conditions are my responsibility and the responsibility of my personal physician.
Furthermore, I understand that the physician may recommend, on the basis of his experience and that of his colleagues, published papers in the Bariatric (weight management) and nutritional literature, and ongoing clinical trials, that I use appetite suppressants for significantly longer periods of time and at higher doses than indicated on the labeling of the medication. I understand that the labeling represents the opinion of the drug manufacturer and the Food & Drug Administration. I understand that although the appetite suppressants used in this program have low addiction potential and that I may elect to discontinue their usage at anytime, that I may or may not regain the weight lost while taking the medications. I also understand that the physician considers the risks of long-term administration of these appetite suppressants to be minimal, and appropriate to achieve long-term weight reduction; however, as with the long-term administration of any medication, serious or life-threatening side effects, though highly unlikely, cannot be absolutely excluded.
I understand that there are other means and programs available to me to lose weight utilizing various methods of caloric restriction
and/or exercise without appetite suppressants, but that these methods necessitate greater “will-power” because of unrelieved hunger.
RISKS OF THE WEIGHT LOSS PROGRAM:
I understand that giving my consent for entering the weight loss program may involve the use of appetite suppressants for more than 12 weeks and in higher doses than recommended in the labeling and may expose me to side effects including, but not limited to: nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, medication allergies, and increased blood pressure. These and other risks could conceivably be serious, and in rare cases fatal. I understand there is a risk of developing primary pulmonary hypertension, with the use of appetite suppressants, which is extremely rare and can possibly be fatal if symptoms are ignored and the medications are not discontinued. The most noticeable side effects are unusual fatigue and shortness of breath upon exertion. If I experience these side effects, I understand I should discontinue the medications and call my physician. When the medications are discontinued, the condition is generally 100% reversible. This condition usually takes a period of months to develop, however, cases have been reported where the condition developed in less time. I understand that the medications may have adverse reactions when taken with alcohol or other drugs.
RISKS ASSOCIATED WITH BEING OVERWEIGHT OR OBESE:
I am aware that there are certain risks associated with remaining overweight or obese. Among them are tendencies to high blood pressure, diabetes, heart attack, heart disease, stroke, certain cancers, gallstones, sleep apnea and pulmonary damage, arthritis and damaged joints, hips, knees and feet. I understand these risks may be modest if I am not very much overweight but that these risks go up significantly the more overweight I am.
