Medical Weight Loss Centers of America

Telehealth Consent Forms

Informed Consent for Telemedicine Services

Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care clinicians, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

  • Patient medical records
  • Medical images
  • Live two-way audio and video
  • Output data from medical devices and sound and video files
  • Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. Responsibility for patient care remains with the patient’s local clinician, as does the patient’s medical record.

Expected Benefits

  • Improved access to medical care by enabling a patient to remain in their home while receiving medical care.
  • More efficient medical evaluation and management.
  • Save time, money, and convenience.
  • Obtaining the expertise of a specialist.

Possible Risks

As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to, the following:

In rare cases, the consultant may judge that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with the patient.

Delays in medical evaluation and treatment could occur due to limitations or failures of the equipment.

In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.

In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

Patient Acknowledgement

By agreeing to a Medical Weight Loss Centers of America consultation and treatment by a Medical Weight Loss Centers of America board-certified physician, the patient indicates an understanding of the following:

I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine and that no patient identifiable information obtained in the use of telemedicine will be disclosed to researchers or other entities without my consent.

I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.

I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.

I understand the alternatives to telemedicine consultation as they have been explained to me, and in choosing to participate in a telemedicine consultation, I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the consulting health care provider.

I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners involved in my care who may be located in other areas, including out of state.

I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

I understand that individuals other than my health care provider and consulting health care provider may be present and that they will maintain the confidentiality of the information obtained. I further understand that I will be informed of their presence.

I have read and understand the Informed Consent for Telemedicine Services as posted on this page, have discussed it with my clinician or such assistants as may be designated, and all of my questions have been answered to my satisfaction.

All information, imagery, and Content on this site is the property of Medical Weight Loss Centers of America or its wholly-owned subsidiaries including Medical Weight Loss Centers of America. The Content is protected by copyright laws, trademark and design rights. Any unauthorized use of the Content will be considered a violation of Medical Weight Loss Centers of America’s intellectual property rights.

Unless otherwise stated in this document, Medical Weight Loss Centers of America and its subsidiaries reserve all tacit and direct rights to patents, trademarks, copyrights or confidential information relating to the Content. Unless otherwise stated in this document, no Content may be copied, distributed, published or used in any way, in whole or in part, without prior written agreement from Medical Weight Loss Centers of America, except as allowed by the limited license contained in these Conditions of Use.

You may not, and these Conditions of Use do not give you permission to, reproduce, reverse engineer, decompile, disassemble, modify or create derivative works with respect to this Site.

Informed Consent for B Vitamin and Lipotropic Injection Therapy

This document is intended to serve as confirmation of informed consent for injection therapy at Medical Weight Loss Centers of America.

I have informed Medical Weight Loss Centers of America of any known allergies to drugs or other substances, or of any past reactions to injections. I have informed the doctor of all my medical conditions and current medications. I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent.

I understand that:

  1. The procedure involves inserting a needle into various areas of the body   and injecting of vitamins and other homeopathic remedies.
  2. Risks of injection therapies include but are not limited to:
  3. Occasionally to commonly
  • Discomfort, severe pain, bruising, inflammation, injury and numbness at the site of injection.
  •  Fatigue, dizziness, or light-head feeling after the injections.
  •  Fainting or loss of consciousness during the procedure.
  1. Extremely rare:
  •  Severe allergic reaction, anaphylaxis, infection.

I am aware that other unforeseeable complications could occur. I do not expect Medical Weight Loss Centers of America to anticipate and or explain all risk and possible complications. I rely on the technician to exercise judgement during the course of treatment with regard to any procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered. I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance.

When purchasing Vitamin B or Lipotropic Injections from Medical Weight Loss Centers of America, you agree to the following:

  • I have given my consent to injection therapy with any different or further procedures which, Medical Weight Loss Centers of America, may be indicated.
  • I understand the information provided on this form and agree to the foregoing.
  • The procedure(s) set forth above has been adequately explained to me
  • I have received all the information and explanation I desire concerning the procedure.
  • I authorize and consent to the performance of the procedure(s).

GLP-1 Medication Consent Form

By proceeding with the use of our services and treatments, you consent to the following terms and conditions regarding GLP-1 medications offered by Medical Weight Loss Centers of America:

  1. Photography and Video Consent: You consent to have your pictures and/or videos taken and stored in our electronic medical record system. Such photographs and videos will only be used for internal training purposes unless we obtain your express permission for other uses.

  2. Financial Responsibility: All services rendered to you are charged directly to you, and you are personally responsible for payment prior to receiving services. In the event of non-payment, cancellation of payment, or any payment issues, you agree to bear the cost of collection, court costs, and legal fees, should those be required.

  3. Rewards Program Enrollment: You consent to be signed up for our free rewards programs to earn points and get discounts on your treatments.

  4. Communications Consent: You consent to receive email, text, and phone communications related to post-procedure care and follow-up appointments. Additionally, you consent to receive promotional and marketing messages via email, phone, and SMS messages.

  5. Medical Conditions and Compatibility: By using GLP-1 medications, you affirm that none of the following conditions apply to you as they are not compatible with the use of GLP-1 medications:

    • Personal or family history of Medullary Thyroid Carcinoma (MTC)
    • Personal or family history of Multiple Endocrine Neoplasia, type 2 (MEN 2)
    • Prior allergic reaction to any GLP-1 medication or its ingredients
    • Diabetic retinopathy
    • Pregnancy or attempting to get pregnant
    • Breastfeeding
    • Under 18 years old
    • Depression with a history of suicidal thoughts

    Additionally, any of the following conditions may create problems and should be discussed with a doctor before treatment:

    • History of pancreatitis
    • Kidney disease/kidney insufficiency
    • Stomach problems
    • Diabetes (must obtain approval from an endocrinologist or primary care physician)
  6. Post-Procedure and Medical History: You are required to attend post-procedure check-ups as advised and follow all post-treatment instructions. You confirm that you have provided your complete medical history, including all previous conditions and current medications.

  7. Treatment and Risks: Alternatives to the procedures and options have been fully explained to you. You consent to the administration of any necessary or advisable anesthetics. You understand that all forms of anesthesia and aesthetic procedures involve risk and the possibility of complications and injury. No guarantees or promises have been made concerning the results of this procedure or any treatment that may be required.

  8. Refund Policy: You understand there are no refunds and that multiple treatments may be required to achieve noticeable and lasting outcomes. Promotional items have no refund value.

  9. Product and Service Agreements: No agreement to sell products or services is formed until an order is placed and approved by Medical Weight Loss Centers of America. The terms of such agreements will be those of our standard procedures and applicable laws. Self-administration of any product must follow provided instructions.

  10. Drug Interactions and New Medications: You agree to inform Medical Weight Loss Centers of America about all medications, over-the-counter drugs, vitamins, and supplements you are currently taking and not to start new medications or supplements without informing us. Use of steroids or antibiotics may reduce effectiveness and slow weight loss.

  11. GLP-1 Medication Information: GLP-1 medications are weight loss medications given by weekly injection and are FDA approved. They work by slowing digestion, suppressing appetite and cravings, and lowering glucose levels. Injections are given under the skin of the thigh, stomach area, or upper arm, once a week. Missed injections should be taken within two days, but the injection schedule will change accordingly.

  12. Fluid Intake and Side Effects: It is important to drink plenty of fluids while on GLP-1 medications. Side effects can include nausea, vomiting, diarrhea, and constipation. Less common but serious side effects should be reported immediately, such as allergic reactions, breathing problems, changes in vision, severe nausea, or symptoms of infection.

  13. Rapid Weight Loss Warning: Rapid weight loss can cause serious health problems. Consultation with a personal physician is advised before starting any weight-loss program. Permanent lifestyle changes are essential for long-term weight loss.

  14. Arbitration Agreement: Any legal dispute, controversy, demand, or claim that arises out of or relates to the services provided will be resolved exclusively by binding arbitration. This agreement covers all claims related to the treatment or services provided.

By continuing to use our services and treatments, you acknowledge that you have read, understood, and agree to the terms and conditions outlined in this consent form. Your continued use of our services constitutes your consent to these terms.

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