MEDICAL WEIGHT LOSS

By adding my name below I do willingly request and consent to the premier weight loss programme. To experience success on this program it is mandatory that I follow the diet protocol explicitly. I understand that there is no warrant or guarantee of results due largely to off-site administration and patient-controlled application. 1. I understand that as part of this program I will be required to complete a Medical History, listen to an orientation of the program where I will be instructed on how to administer the injections myself, or make arrangements to have someone assist me. I understand that initial blood tests may be required in order to rule out any conditions that would disqualify me from the program or require any prior treatment before starting the program. I agree to immediately report any problems that might occur to my counselor or coordinator as well as my Primary Physician during the treatment program. 2. I understand that there could be risks involved, as there are with all medications. Failure to comply with the dosage recommendation and dietary restrictions could the weight loss results. 3. I agree that I am, and will be, under the care of my primary medical provider for all other conditions. I understand that the medical providers who administer weight loss therapies or any program cannot replace my regular Primary Care Physician or General Practitioners or other specialists in Family Medicine or Internal Medicine. 4. I understand that treatments for weight loss are rarely covered by insurance companies. We do not accept or bill insurance for this program. 5. I understand that results may vary and I understand that any requests for a full or partial refund will NOT be honoured. Your prescription is in your individual name and cannot be returned. 6. I have read and understand all of the above statements and conditions and have been informed of potential side effects and risks that may be associated with the diet protocol. I fully understand what I am signing and hereby request and consent to weight-loss treatment. I have disclosed my full medical history and I have been made aware of the benefits, side effects and/or rare possible adverse reactions of various treatments. I acknowledge that all statements provided on these forms, and the Confidential Health History Forms are true and accurate to the best of my knowledge and that my treatments will be based on the information provided herein and if I willingly withhold information, I accept full liability for any consequence that may arise therefrom.