HIPAA/Informed Consent
We are happy you joined us for your weight loss journey! With this email, you have a link to our discharge instructions, protocols, and injection guidelines.
HIPAA Disclosure
- This privacy notice contains a thorough and complete description of the uses and / or disclosures of my protected health information (“PHI”) which are necessary to provide me with treatment, and which are also necessary for the Practice to obtain payment for that treatment and to perform other healthcare operations. I have been informed that, upon my request, the privacy notice will be made available to me. Prior to signing this Agreement, the Practice advised me of my right to obtain a copy of the Privacy Notice and has encouraged me to read it in its entirety, in accordance with applicable law.
- To Protect your privacy and to remain in compliance with applicable law, the Practice reserves the right to Change the practices depicted in its Privacy Notice.
- I am aware that the Practice’s “Notice of Privacy Practices” is displayed in the waiting area and that I am free to request a copy of the same at any time.
- The Notice of Privacy Practices Contains my rights, as well as the duties and obligations of this office as it relates to my protected health information.
Informed Consent
At the appointment scheduled, you will receive a consultation by a state licensed NP/PA/MD regarding our weight loss program. After you speak with the provider, he or she will decide whether or not you are a candidate for treatment with our GLP-1 medication for weight loss – Semaglutide or Tirzepatide. The medication is given subcutaneously weekly and may have some side effects such as mild nausea or stomach cramping as you are adjusting to it. You will be provided medication to combat the nausea. Some patients also experience indigestion, but this is usually mild and relieved with over-the-counter antacids. Persons with a family history of thyroid cancer or multiple endocrine neoplasia syndrome, or a history of pancreatitis will be precluded from being prescribed this medication at the discretion of the clinician. Additionally, it has been noted that GLP-1 agonists have been proven in some instances to cause bowel obstruction, ileus (bowel paralysis), gastroparesis and pancreatitis. Taking these medications for weight loss is off label and elective.
I fully understand the nature of the medication described above and the possible side effects. I agree to pay a medical consultation fee at the price disclosed at time of booking upon completion of my visit, and I am aware that purchases of any other medications I elect are final and nonrefundable. I understand I am enrolling in a weight loss program, but should the doctor not clear me medically to receive the treatment, my initial consultation will not be refunded, however, any payment beyond the initial consultation fee will be refunded in the manner it was paid. I understand my monthly participation fee, which covers my ongoing monitoring and my medication, will be charged automatically each month and can be canceled at any time. I consent to treatment by the Unique Physique physician/provider I am scheduled with. I acknowledge that these services are considered to be elective treatments, and that they are not covered by Medicare or most other insurance providers. Any medications ordered by me are non-returnable in accordance with applicable laws. I understand that I must cancel any medication order after the first month prior to its submission to the pharmacy in order to receive a refund.
