These problems may include heart palpitations, irregular beats, or rapid heartbeat. These effects are usually mild but can result in serious problems including heart attack or stroke. Also, these medications may increase blood pressure, which if left untreated can lead to heart attack or stroke. If you discontinue the weight loss medication, the elevated blood pressure usually resolves. For this reason, if you are on blood pressure medications you are required to monitor your blood pressure daily and discontinue medications if blood pressure rise, your heart rate increases, or you feel palpitations.

Patients with morbid obesity, particularly those with hypertension, heart disease, or diabetes, have a statistically higher chance of suffering sudden death when compared to normal- weight people without such medical problems. Rare instances of sudden death have occurred while obese patients were undergoing medically supervised weight reduction, though no cause and effect relationship with the diet has been established. The possibility cannot be excluded that some undefined or unknown factor in the treatment program could increase this risk in an already medically vulnerable patient.

Any program resulting in rapid weight loss may precipitate the formation of gallstones, which could lead to cholecystitis (inflammation of your gallbladder), which is a medical urgency or emergency and could require surgery. This is typical because of the rapid weight loss, not the medications you are taking. Symptoms include right upper abdominal pain, abdominal just below your ribs, nausea, and vomiting.Any program resulting in rapid weight loss may precipitate the formation of gallstones, which could lead to cholecystitis (inflammation of your gallbladder), which is a medical urgency or emergency and could require surgery. This is typical because of the rapid weight loss, not the medications you are taking. Symptoms include right upper abdominal pain, abdominal just below your ribs, nausea, and vomiting.

Pancreatitis, or an infection in the bile ducts, may be caused by gallstones or the development of sludge or obstruction in the bile ducts. The symptoms of pancreatitis include pain in the left upper abdominal area, nausea, and fever. Pancreatitis may be precipitated by binge- eating or consuming a large meal after a period of dieting. Pancreatitis is long-term abuse of alcohol and the use of certain medications and increased age. Pancreatitis may require surgery and may be associated with more serious complications and death.

There are reported cases of “hysterical or psychotic reactions” associated with the use or discontinuation of some of the drugs utilized for weight loss purposes. These reactions are extremely rare.

Common, but troublesome side effects may include but not be limited to: dry mouth, palpitations, “speedy” feeling, headaches, sleeplessness., Rash, fever, nausea, vomiting, allergic reactions, decreased insulin sensitivity, flushing, headache, fatigue, lightheadedness, abdominal cramping, joint pain, fluid retention, and additional side effects not listed that will be discussed during your

evaluation with Total Health Care Clinic. These side effects are generally rare, and most patients tolerate treatment without an issue.

Drug interactions may occur if other medications are taken. Therefore, I will check with my prescribing medical provider before starting the program if I am taking other medications.

Certain medical conditions may be worsened if on this program, including glaucoma, hypertension, and heart disease.

If you become pregnant, inform your healthcare provider immediately. Your diet must be changed promptly to avoid further weight loss because a restricted diet could be damaging for a developing fetus. You must take precautions to avoid becoming pregnant during the course of weight loss.

The use of medications for weight management is indicated for those patients who have a BMI of 30 or higher or a BMI of 27 or higher with other medical conditions such as high blood pressure, diabetes, or high cholesterol. Prescribing medications maybe considered “off label” and not “FDA approved.” Therefore, the potential risks vs. benefits may be great. Please acknowledge that:
a. You have put forth a true effort to lose weight through diet and exercise over the past 6 months and have still not achieved your weight loss goals.
b. You are choosing to enter this medically managed weight loss program voluntarily and hold harmless Total Health Care Clinic for use of such medications.

I acknowledge that I understand that the amount of weight loss varies from patient to patient, and is, to a large extent dependent on each patient’s motivation and commitment to their diet and exercise plan. No claims as to efficacy or a specific amount of weight loss is either expressed or implied. I understand the importance of routinely following up to monitor my progress during treatment. I understand this is vital to the safety of the treatment program

I hereby allow Total Health Care Clinic to evaluate me and treat me accordingly. I consent to obtain blood work before treatment if deemed necessary. I certify that I am signing this under my free will and am competent to make my own medical decisions.

I have reviewed the mentioned risks and have determined the benefits outweigh the possible risks associated with medically managed weight loss therapy with Total Health Care Clinic I release any claim in court or any type of complaint that could result from treatment with Total Health Care Clinic, (Geraldine Hawkins) and any other staff associated with Total Health Care Clinic and will not hold liable any provider or staff.

I also understand that many of the medications being utilized within Total Health Care Clinic medically managed weight loss program maybe considered to be used “off label” and might not be FDA approved for weight loss purposes.

According to FDA Policy Sec. 460.300, I acknowledge that I cannot return or receive refunds for medications and/or injections once the medications/injections leave the office regardless of effectiveness or possible adverse reactions.

I acknowledge that I have had an opportunity any concerns and the above information with Total Health Care Clinic, either in person or by telephone conversation. I consent to the treatment being offered to me by Total Health Care Clinic and I am satisfied with the explanation.

I acknowledge that I have read or have had read to me the above consent and understand the information presented.