Consent For Use of Weight management Medications

CONSENT FOR USE OF WEIGHT MANAGEMENT MEDICATIONS

NOTE: SIGNING THIS FORM DOES NOT GUARANTEE THAT YOUR PROVIDER(S) AT LAKEVIEW CARDIOLOGY WEIGHT MANAGEMENT CLINIC WILL FIND YOU TO BE AN APPROPRIATE CANDIDATE FOR WEIGHT MANAGEMENT MEDICATIONS, BUT ONLY THAT YOU HAVE READ, UNDERSTOOD, AND AGREE TO THE TERMS OF MEDICATION USAGE SHOULD YOU AND LAKEVIEW CARDIOLOGY DECIDE UPON THEIR USAGE NOW OR IN THE FUTURE. Some WEIGHT MANAGEMENT medications are considered “controlled medications.” By law, a controlled medication can only be prescribed from one facility at a time; therefore, I agree that only LAKEVIEW CARDIOLOGY WEIGHT MANAGEMENT CLINIC will prescribe WEIGHT MANAGEMENT medications for me. I agree that it is my responsibility to inform my provider(s) at LAKEVIEW CARDIOLOGY WEIGHT MANAGEMENT CLINIC and any other providers from whom I receive treatment of all medications prescribed to me. I understand that the use of WEIGHT MANAGEMENT medications is contraindicated with certain medical histories, allergies, or other medication use. I agree that I will be honest in disclosing this information and will notify my provider(s) at LAKEVIEW CARDIOLOGY WEIGHT MANAGEMENT CLINIC of any changes to my medical history or medication usage. I understand that failure to do so can be dangerous to my health. I agree to take the medication only as prescribed and directed by LAKEVIEW CARDIOLOGY WEIGHT MANAGEMENT CLINIC. I understand that taking medications in any way other than as directed and prescribed could affect my health and be dangerous. I understand that the use of some of the WEIGHT MANAGEMENT medications beyond 12 weeks is considered “off label” or not initially approved by the U.S. Food and Drug Administration (FDA). I understand that my provider(s) at LAKEVIEW CARDIOLOGY WEIGHT MANAGEMENT CLINIC are experienced specialist(s) in obesity medicine who will, at times, elect or choose, when indicated, to use the WEIGHT MANAGEMENT medication(s) for longer periods of time as deemed appropriate for my individual treatment. I understand that I am to report any side effects or adverse reactions of my medications to my provider(s) at LAKEVIEW CARDIOLOGY WEIGHT MANAGEMENT CLINIC. I understand that it is my responsibility to follow the instructions carefully and that the purpose of this treatment is to assist me in my desire to decrease my body weight for improvement of health and to maintain weight loss. I understand that the purpose of medications for weight loss is to be used as an adjunct to a program that includes nutrition and/or physical activity and/or behavior modification. I understand that much of the success of the program will depend on my efforts and that there are NO GUARANTEES in medical treatment of the disease of obesity. I also understand that I will have to continue monitoring my weight after active weight loss.