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Please complete and submit this form prior to your appointment. This form has 7 pages that include registration, medical history, lifestyle information, and treatment waiver.
Primary Care Doctor:
Please check all that apply to you biological relatives
Please read this waiver and sign below.
You are about to begin a weight loss program using medications that have been approved individually by the FDA. The manufacturer's insert recommends these drugs for short-term use in the treatment of weight loss. However it is important to note that sometimes the doses, drug combination and duration of treatments are "off label" which means that it is legal and perfectly acceptable for doctors to use these therapies according to their best judgment and medical experience. While potential exists for class IV drugs, a four year study showed NO abuse or dependence. We treat overweight and obesity as chronic illnesses, which sometimes require multi-drug therapy and long-term maintenance. This is similar to treating high blood pressure, diabetes and other chronic conditions which are "controlled" but not "cured". You may gain weight if the medication is discontinued. These medications should NOT be taken if you have untreated angina (chest pain), glaucoma, untreated hypertension (high blood pressure), hyperthyroid disease, or an allergy to sympathomimetic medications (such as Sudafed) or if you are pregnant, can become pregnant, or are breastfeeding. There is the possibility of certain side effects including, but not limited to; dry mouth, insomnia, dizziness, nervousness, diarrhea or constipation, fast or irregular heart beat. These side effects are usually mild and disappear within the first 2-4 weeks as your body adjusts to the medication. Please inform your physician if you experience any uncomfortable or persistent side effects. Inform your physician if you are allergic to Phentermine or any other medications; what other medications you are currently taking (prescription or non-prescription); If you have ever suffered from a heart condition, high-blood pressure, arteriosclerosis, overactive thyroid, diabetes, glaucoma, or have a history of drug abuse.
Semaglutide is FDA Approved for diabetes and weight loss. Tirzepatide is FDA Approved for diabetes and NOT yet FDA Approved for weight loss. However, it is used “off label” by our Medical Providers to reduce appetite. Semaglutide and Tirzepatide are synthetic analogs of the human glucagon-like peptide-1 (GLP-1) hormone. These medications act as GLP-1 receptor agonists, which help regulate blood glucose levels, slow gastric emptying, and increase satiety, thereby contributing to weight loss. Semaglutide and Tirzepatide are used by our providers to treat patients who are overweight–high risk personal or family history of comorbid diseases (hypertension, Obesity, High cholesterol) or patients who are obese. You may gain weight if the medication is discontinued.These medications combined with routine guidance from our providers, along with the recommended dietary changes, routine exercise, can help patients achieve gradual weight loss. These Treatments also have many possible side effects however they are generally well tolerated by most patients. Additionally, the side effects tend to improve over time with usage and sometimes can also be prevented by limiting foods that commonly trigger these side effects. Most common triggers include high fat, high sugar, and alcohol containing foods. If you notice any side effects, let your provider know. If you notice severe, life threatening, intolerable side effects, seek emergency help.I acknowledge that there are potential risks and side effects associated with the use of Semaglutide and Tirzepatide. Common side effects include but are not limited to: nausea, vomiting, diarrhea, constipation, abdominal pain, decreased appetite, and injection site reactions.Rare but serious side effects may include: pancreatitis, gallbladder disease, hypoglycemia, kidney problems, and allergic reactions. GLP-1s MAY DECREASE Effect of Oral Birth control. Barrier Methods are recommended to decrease chances of pregnancy within two months of using GLP1-s or changing of your dosages. Do Not Take If: Allergic to GLP-1 (Trulicity, ozempic, saxenda, Semaglutide, dulaglutide), Pregnant or planning to get pregnant in next 2 months, breastfeeding or planning to breast feed, personal or family history of medullary thyroid cancer or multiple endocrine neoplasia syndrome type two, suicidality history or active suicidal ideation. I understand that these medications may not be appropriate for all patients, and the Physician will evaluate my medical history and current health status before prescribing these medications.
Vitamin B12 is vital for proper bodily functions, including brain function and the production of DNA and red blood cells. It may be administered through injections, especially for individuals who have difficulty absorbing this vitamin. Lipotropic Injections contain compounds that assist in the breakdown of fat in the liver, aiding in weight loss and supporting overall liver function.I understand and acknowledge that there are potential risks, side effects, and benefits associated with Vitamin B12 and Lipotropic Injections. Common side effects may include: mild pain, redness, or irritation at the injection site, mild diarrhea, and swelling sensation in the body. Rare but serious side effects may include: Unusual weakness, numbness, or tingling of the arms or legs, and allergic reactions, symptoms of which may include difficulty breathing, swelling of face/lips/tongue/throat, rash, and severe dizziness.
I understand that the purpose of this medical weight loss program is to assist me in achieving my weight loss goals and maintaining a healthy weight through the use of medications, lifestyle modifications, and dietary guidance. I acknowledge that there are alternative treatments and weight loss methods available, including but not limited to: diet and exercise programs, behavioral therapy, other weight loss medications and bariatric surgery. I understand that I am under no obligation to participate in this weight loss program and that I may choose an alternative method at any time.
While receiving treatment at Transradiant, be sure to let all of your medical providers know ALL of your medical history, medication changes, supplements, pregnancy status or plans to get pregnant, breastfeeding status, recent hospitalizations, upcoming procedures, or changes in health–at each visit. I acknowledge that I have read the above information. I do not have any of the above mentioned conditions that would make these treatments contraindicated. I will inform all of my medical providers at Transradiant as well as my entire medical team outside of Transradiant Health, of all of my medication usage, new treatments, planned surgeries, pregnancy and overall changes in health status. I am aware that other unexpected risks or complications may occur and that no guarantees or promises have been made to me concerning the results of treatment. I also understand that during the course of the proposed treatment, unforeseen conditions may be revealed requiring performance of additional procedures to be covered at my own expense and will not hold Transradiant Health accountable for additional fees. I have read and understand the information provided in this disclosure and consent form. I understand I will have had the opportunity to ask any questions and to receive answers about this weight loss program. I understand that the medications are dispensed for my convenience and I am free to choose a written prescription in lieu of dispensing. Prescription drugs may be purchased if a pharmacy is not conveniently available to me (the patient). The determination that a pharmacy is not available to me (the patient) is made solely by me (the patient). I hereby agree to the treatment plan of Transradiant Health and I understand that the outcome cannot be guaranteed.
You acknowledge and understand that Transradiant Health does not participate with any health insurance companies or plans, and has no contractual obligations with such. You agree that you are responsible for any payment obligations which may arise from the services received.
I understand that my medical information related to this weight loss program will be kept confidential and will only be shared with my healthcare team and other authorized personnel as required by law.
By signing below, I acknowledge that I have read and understood the information provided in this consent form. I understand I will have the opportunity to discuss the risks, benefits, and alternatives to treatment with the provider. I hereby provide my voluntary informed consent to participate in this medically supervised weight loss program using oral appetite suppressants, compounded Semaglutide or Tirzepatide, and/or Lipotropic or B12 injection alone or in any combination under the care and guidance of Patrick Desamours.
This form confirms your agreement and understanding regarding the use of telehealth services and electronic communications provided by Transradiant Health
Telehealth involves the delivery of healthcare services, including medical advice, healthcare information, and other services, using interactive audio, video, and data communications. This means that you, the patient, and your healthcare provider may not be in the same physical location during your healthcare services.By signing this waiver, you acknowledge and agree to the following:a. You understand that while telehealth services have been found to be effective in a wide range of medical situations, no specific results can be guaranteed or assured.b. You understand that telehealth services may involve electronic communication of your personal medical information to other healthcare practitioners who may be located in other areas, including out of state.c. You understand that you have the right to withhold or withdraw your consent to the use of telehealth services at any time, without affecting your right to future care or treatment.
By signing this waiver, you consent to the use of electronic communication (such as email, text messages, video conferencing, and online patient portal systems) in the course of your care.You acknowledge and understand:a. The use of electronic communication to discuss sensitive medical information does carry some level of risk. While the provider uses secure, encrypted email and messaging systems, these electronic communications can be intercepted.b. You understand that you are responsible for providing the provider with your most current and accurate contact information.c. You have the right to revoke your consent to the use of electronic communication at any time by written communication to the provider.By signing this waiver, you represent that you have read and understood the information provided above, and you consent to the use of telehealth services and electronic communication in your medical care.
We understand that there are times when you must miss an appointment due to emergencies or obligations. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise when another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly “full” appointment book.A “no show” is someone who misses an appointment without canceling it within 24 hours in advance. Patients who fail to show up for their scheduled appointment or did not notify the office within 24 hours of their scheduled appointment time, shall be subject to a “No Show/Cancellation” fee of $25.00. In the event of an emergency, and prior notice could not be given, consideration will be given, and a one-time exception may be granted.
Please call our office at any time. If you receive the answering machine, please leave a message with your full name, phone number, appointment time and date, and when you would like to reschedule your appointment.
Please Arrive 10 min Prior to your appointment. We understand that delays can happen, however, we must try to keep the other patients and doctors on time. If you are running late, please notify the office. We may have to reschedule your appointment if you are not present inside of the clinic within 10 min of an office closure (Lunch Break, Office closing Times, Vary by location, Posted online).
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