Weight Loss Consent Forms

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Weight Loss Consent Forms

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WEIGHT LOSS PROGRAM CONSENT FORM

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I hereby authorize Dr. Joelle Osias and ForeViva Medical Clinique staff, to assist me with weight reduction. I fully understand that this program will consist of diet and exercise guidelines, including recommendations for behavioral lifestyle modifications to further support optimized health and wellness. In addition, the provider may recommend a customized plan of care tailored towards reaching my goals. This customized plan of care may include the use of: appetite suppressants, nutritional vitamin injections and/or infusions, peptide therapies and supplements. I further understand that the prescribed treatments will be at the discretion of the treating provider following an initial consultation encounter and full review of relevant medical history. Routine follow-up encounters EVERY 6 MONTHS are an important part of any successful treatment plan and are required for optimal results and to provide for continuity of care. Regarding the use of appetite suppressants, as with any prescription medication, I understand that there are potential risks involved. Side effects may include nervousness, constipation, insomnia, headaches, dry mouth, weakness, fatigue, medication allergy, increased blood pressure and increased or irregular heart rate. I understand that these and other risks could be serious or in rare cases life threatening.

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I understand that if I develop side effects from the medication, I will discontinue taking the medication and notify the ForeViva Medical Clinique staff immediately and in the event the problem is severe, I will go to the nearest Emergency room for immediate care. I do not have a history of alcohol abuse, drug abuse, schizophrenia, manic-depressive illness, or eating disorder, since these conditions constitute a contraindication to the use of appetite suppressants.

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I agree not to take any other weight loss medications, other than those prescribed by ForeViva Medical Clinique and further agree to inform the staff of ANY changes in my medication or medical history.

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I understand that I can be successful without the use of appetite suppressants or injections as long as I am following a reduced calorie nutrition plan and increasing my activity level, however the use of such medications and injections may significantly help with my weight loss progress. I understand the risks associated with being overweight or obese can include the following: high blood pressure, diabetes, heart, disease, stroke, arthritis, pain of the joints, gallbladder disease and even sudden death.

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I understand that there is no guarantee that this program will work for me. I also understand that there are no refunds, no credit, no returns. ALL SALES FINAL!

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By consenting to treatment, I agree to pay, in full, for all visits and charges incurred at each visit, including but not limited to lab fees and/or lab follow up consultations. I understand that ForeViva Medical Clinique does not accept insurance and all services must be paid in full. No credit will be issued. We accept Visa, MC, AMEX, Discover, CareCredit and cash.

By signing below I certify that I have read and fully understand this consent form and understand the risks and benefits associated with my treatment for weight loss.

Patient Name

First

Last

Signature of Patient or Legal Guardian

Date

B12 & AMINO ACID INJECTIONS INFORMED CONSENT

Vitamin B-12 helps maintain good health and has been shown to be beneficial in helping to: Reduce stress, fatigue, improve memory and cardiovascular health, and maintain a good body weight. It can also assist the body in converting proteins, fats and carbohydrates into energy and is necessary for healthy skin and eyes. Amino Acids help the liver to cleanse the body of toxins and assists the body in metabolizing fat and cholesterol. They may also be helpful in reducing fatigue and the symptoms of allergies.

B12 and Amino Acid Injections are better absorbed by the body since they go directly into the bloodstream. Alternatives to these injections are Oral Vitamins, B12 Patch, Lozenges, Liquid drops and Nasal Spray.

B12 and Amino Acid Injections common side effects include but are not limited to:

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1. Risks: I understand there is risk of mild diarrhea, upset stomach, nausea, a feeling of pain and a warm sensation at the site of the injection, a feeling, or a sense of being swollen over the entire body, headache and joint pain.

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2. If any of these side effects become severe or troublesome I will contact my physician immediately.

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3. I understand that although rare Vitamin B12 and Amino Acid injections can result in serious side effects. Although this is a relatively rare occurrence, anyone taking vitamin B12 or Amino Acid injections should be aware of the possibility. Uncommon side effects are much more serious than the common side effects of B 12 and Amino Acid injections, and such side effects should be reported to a physician to be evaluated for seriousness. Uncommon and dangerous side effects include: rapid heartbeat, chest pain, heart palpitations, flushed face, restlessness, muscle cramps and weakness, difficulty breathing and swallowing, dizziness, confusion, rapid weight gain, tight feelings in the chest, hives, skin rashes, shortness of breath when there is no physical exertion, unusual wheezing.

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4. Before starting vitamin B12 or Amino Acid injections I will make sure to tell my Physician if I am pregnant, lactating or have any of the following conditions: Leber's Disease, Kidney disease, Liver disease, An infection, Iron deficiency, Folic acid deficiency, Receiving any treatment that has an effect on bone marrow, An allergy to cobalt or any other medication, vitamin, dye, food or preservative

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5. I understand that certain herbal products, vitamins, minerals, nutritional supplements, prescription and nonprescription medications may result in side effects when they interact with the B12 or Amino Acid Injection.

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6. Treatments: Can be once a month, Once a week, or Twice a week and will be determined by the provider.

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I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I further agree in the event of non-payment, to bear the cost of collection, and/or Court costs and reasonable legal fees, should this be required.

By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks. I hereby give consent to perform this and all subsequent B12 and Amino Acid Injections with the above understood. I hereby release the doctor, the person injecting the B12 and Amino Acids, and the facility from liability associated with this procedure.

At ForeViva we specialize in several non-invasive treatments, we do not offer any surgical procedures.

Patient Name

First

Last

Signature of Patient or Legal Guardian

Date

FINANCIAL RESPONSIBILITY CONSENT

All professional services rendered are charged to the patient and due prior to service.

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I have requested medical services from ForeViva Medical Clinique and affiliates on behalf of myself and/or dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.

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I understand that ForeViva Medical Clinique does not accept insurance and that fees are due and payable prior to services rendered and I personally agree to pay all such charges in full. I have requested these medical services and take full responsibility for all shipments made to the location of my designation for all treatments prescribed for me by ForeViva Medical Clinique and its affiliates.

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I understand that there are no returns, exchanges and/or credit as all sales are final. I agree to pay for any and all encounters made either in person, virtual, email, phone, lab fees and/or lab follow up consultations.

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I agree that I will not cancel any credit card payment to ForeViva Medical Clinique, or any of its affiliates for the services I have requested. A fax, scan or photocopy of this agreement is to be considered as valid as the original. Patient / Responsible Party

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I agree to the deposit fee of $150 to secure an appointment time for a procedure or for any appointment encounter with a provider. This deposit amount will be credited towards the cost of any product and or services provided at the appointment/encounter. Should the client fail to cancel the appointment more than 48-hours in advance then the $150 deposit fee will be forfeited.

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I agree to the charge of $100 should an appointment made by me not be canceled more than 48 hours prior to the scheduled appointment.

Patient Name

First

Last

Signature of Patient or Legal Guardian

Date

HIPAA INFORMATION AND CONSENT FORM

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a "friendly" version. A more complete text is posted in the office. What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information
necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services.www.hhs.gov We have adopted the following policies:

1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient's condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.

2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U. S. mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.

3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.

4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.

5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the provider.

6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.

7. We agree to provide patients with access to their records in accordance with state and federal laws.

8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.

You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

Patient Acknowledgment

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I acknowledge that I have read and understand this document

Patient Name

First

Last

Signature of Patient or Legal Guardian

Date

SEMAGLUTIDE INFORMED CONSENT

What is Semaglutide?
Semaglutide (Brand name Ozempic) is an injectable medication which, when used in combination with diet and exercise, helps with blood sugar control in type 2 diabetics. Semaglutide belongs to a class of medications called glucagon-like peptide-1 (GLP-1) agonists, which mimic the hormone GLP-1 in your body to lower blood sugar levels after you've eaten a meal.

What is the hormone GLP-1?
Glucagon-like peptide 1 (GLP-1) is a hormone that causes huge effects on the regulation of blood sugar by stimulating glucose-dependent insulin secretion. Insulin is a hormone that promotes sugar uptake by the cells, stores sugar as glycogen, promotes the building of fat, and signals the body to build skeletal muscle. In addition, GLP-1 inhibits glucagon release (which slows down the release of sugar into the blood so that you burn more fat), slows down gastric emptying (makes you feel full), and lowers the desire for food intake (because you feel full).

Is Semaglutide a type of insulin?
No, Semaglutide is not a type of insulin or a substitute for insulin. Semaglutide does stimulate your pancreas to release insulin when glucose (sugar) is present. Because Semaglutide relies upon your body's own insulin to have this effect, Semaglutide isn't used when your pancreas can't make insulin, such as in patients in type 1 diabetes.

Is Semaglutide a stimulant?
No, Semaglutide is not a stimulant. While other weight loss medications, like phentermine, have stimulating effects that help curb your appetite, Semaglutide works differently (see above).

How does Semaglutide work for weight loss?
GLP-1 agonists like Semaglutide help to control your blood sugar, but people taking them also tend to lose weight. GLP-1, the key hormone involved, slows down how fast your stomach empties food (called gastric emptying). And in addition to causing your pancreas to release insulin, Semaglutide also blocks a hormone that causes your liver to release sugar (glucagon). Together, these functions can help you feel less hungry, causing you to eat less food and lose more weight.

Does Semaglutide curb your appetite?
Yes, it is believed that Semaglutide can help curb your appetite. In addition to slowing gastric emptying to make you feel full for longer, GLP-1 also plays a direct role in how your appetite is regulated.

How long does it take to lose weight on Semaglutide?
With Semaglutide, you will slowly work your way up to the target dose at which time you will see the most amount of weight loss. This was the case in the clinical trials, where participants had their dose adjusted until they reached 2.4 mg once weekly. In the phase 3 trial that measured outcomes at 20 weeks, most participants were able to reach the full dose and also lost weight as their dose was increased. They saw additional weight loss over the remaining 48 weeks at the full dose. It is important to keep in mind that weight loss can take time, and you'll see the best results when you are using your medication in combination with a healthy diet and exercise. Sometimes the medication may not work for you, or you may not be able to tolerate the full dose due to side effects.

How long should you take Semaglutide for weight loss?
Currently, Semaglutide is only FDA-approved to help with blood sugar control in type 2 diabetes and to lower the risk of major cardiovascular events (like heart attack and stroke) in people with both type 2 diabetes and heart disease. If you are taking Semaglutide for either of these reasons, you'll take it as directed by your healthcare provider since you are using it to manage a chronic condition. But if you do not have type 2 diabetes and are looking to try Semaglutide to help you lose weight, we'll have a better idea of long-term safety once the FDA reviews data for this new indication. What we do know is that study participants received treatment for a period of 68 weeks (about 1.5 years) during each of the four trials conducted by the company.

Is Semaglutide safe?
Yes. Semaglutide is considered to be safe and effective when used as indicated. But safe doesn't mean that there aren't risks. Semaglutide also carries a boxed warning about thyroid C-cell tumors occurring in rodents (with unknown risk in humans), and Semaglutide shouldn't be used if you or your family have a history of certain thyroid cancers. Semaglutide should not be used in people with type-1 diabetes or a history of pancreatitis. Semaglutide should be used cautiously for people on other blood sugar lowering medications.

What is the starting dose of Semaglutide for weight loss?
The dosing being studied for weight loss is 2.4 mg once weekly, which is currently higher than the doses approved in diabetes. What's more, Semaglutide is being studied in a different population: people with a body mass index (BMI) greater than or equal to 30 kg/m2 alone or 27 kg/m2 with at least one weight-related comorbidity (diabetes excluded).

Is Semaglutide covered by my insurance?
No. Semaglutide is not covered by insurance for people who are not diabetic type 2. However, you can get this medication as part of our Semaglutide Weight Loss Program.

How much Semaglutide Weight Loss Program cost?
The initial Semaglutide protocol is between 10-20 weeks, depending on how the patient progresses with the dosing. A patient can stay on Semaglutide for many weeks until optimal weight loss is obtained. The initial 20-week protocol costs $2400 if paid-in-full which includes the appointments with the provider, the medication, monthly supplemental vitamin B injection, supplies needed to administer injections, and routine follow up to be successful. Alternatively, the protocol can be offered on a monthly basis at a cost of $600/month. We do not offer weekly programs or payment plans.

Where will I buy my Semaglutide?
Once enrolled in the program and evaluated by our licensed medical provider, the medication and the supplies will be supplied to you. The price of the medication is included in the program.

What is the dose of Semaglutide?
All patients start on the lowest dose of Semaglutide at 0.5mgs injected subcutaneously into belly fat every week. All patients increase by 0.5mgs weekly as tolerated (slower if nauseated), up to a total weekly dose of 2.5mgs.

Are there any foods or medications you should avoid while on Semaglutide?
Here are a few things to keep in mind if you are on Semaglutide.

First, you'll want to limit how much alcohol you're drinking while taking Semaglutide, especially if you are diabetic. Alcohol can have an effect on your blood sugar, and there is a risk that it may drop too low in combination with Semaglutide, especially if you are drinking on an empty stomach. Alcohol can irritate your stomach, too. This might make you feel worse in combination with some of the GI side effects from the medication.

You'll also want to exercise caution if you are taking any oral medications. Since Semaglutide slows down gastric emptying, this can potentially impact the amount of oral medication your body is absorbing. And while trials haven't shown this to be significant with Semaglutide, you'll want to make sure your provider is aware of any other medications you are taking before starting Semaglutide.

What are the known side effects of Semaglutide?
The common side effects of Semaglutide are:

• Nausea
• Vomiting
• Diarrhea
• Stomach pain
• Constipation

Are there any significant health risks associated with using Semaglutide?
Yes. Semaglutide may cause serious side effects, including:

• Prolonged vomiting: Patients on Semaglutide can develop gastroparesis where the stomach stops moving, and patients vomit considerably. This can lead to dehydration and electrolyte imbalances. Stop using Semaglutide and call your health care provider right away if you have vomiting that persists more than a day.
• Inflammation of your pancreas (pancreatitis): Stop using Semaglutide and call your health care provider right away if you have severe pain in your stomach area (abdomen) that will not go away, with or without vomiting. You may feel the pain from your abdomen to your back.
• Changes in vision: Tell your health care provider if you have changes in vision during treatment with Semaglutide
• Low blood sugar (hypoglycemia): Your risk for getting low blood sugar may be higher if you use Semaglutide with another medicine that can cause low blood sugar, such as a sulfonylurea or insulin. Signs and symptoms of low blood sugar may include: dizziness or lightheadedness, blurred vision, anxiety, irritability or mood changes, sweating, slurred speech, hunger, confusion or drowsiness, shakiness, weakness, headache, fast heartbeat, and feeling jittery.
• Kidney problems (kidney failure): In people who have kidney problems, diarrhea, nausea, and vomiting may cause a loss of fluids (dehydration), which may cause kidney problems to get worse. It is important for you to drink fluids to help reduce your chance of dehydration.
• Serious allergic reactions: Stop using Semaglutide and get medical help right away if you have any symptoms of a serious allergic reaction, including swelling of your face, lips, tongue, or throat; problems breathing or swallowing; severe rash or itching; fainting or feeling dizzy; or very rapid heartbeat.

While no magic weight loss pill currently exists, available medications can help. But they should be used in combination with diet and exercise to get the most benefit and set you up for long-term results.

Keep in mind that these medications may not be covered by insurance, and some tend to be expensive. So if you are interested in a prescription to help you lose weight, you'll want to talk to your pro vider to see which one would be the best fit for you.

Key takeaways:
Semaglutide (Brand name Ozempic) is a medication used to help control blood sugar levels in type 2 diabetes, but studies suggest that it may also help people without diabetes lose weight. Semaglutide may be used in adults with a BMI greater than or equal to 30 mg/kg2 alone or 27 mg/kg2 with at least one weight-related comorbidity such as insulin resistance, hypertension, high cholesterol, heart disease, and gout.

Patient Acknowledgment

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I hereby give my permission for Joelle Osias, MD and Associates of Foreviva Medical Clinique to provide me with medical treatment.

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I understand that Foreviva Medical Clinique does not take medical insurance for services provided at the clinic.

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I understand and agree that all services rendered are charged directly to me and that I am personally responsible for payment. I further agree in the event of non-payment, to bear the cost of collection, and/or court cost and reasonable legal fees, should be required.

Patient Name

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Last

Signature of Patient or Legal Guardian

Date

Provider Signature

Date

Hours

Monday: 8:30am – 5:30pm
Tuesday: 8:30am – 5:30pm
Wednesday: 8:30am – 5:30pm
Thursday: 8:30am – 5:30pm
Friday: 8:30am – 5:30pm
Saturday: Closed, except 1st Sat of the month
Sunday: Closed

Contact

Call: 650-843-0600
Text: 650-519-6565
info@foreviva.com
825 Oak Grove Ave Ste. D101, Menlo Park, CA

Weight Loss Consent Forms