Weight Loss Program Consent Form

Please fill out this form prior to your weight loss consultation. Forms must be sent in at least 24 hours in advance.

Weight Loss Program Consent Form

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PERMISSIONS

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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

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