Test - Medical Weight Loss Centers of America

Name*

First Last

Email*

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Date of Birth*

Phone Number*

Gender*

Address*

Street Address Address Line 2 City State ZIP Code

Primary Care Physician

Physician's Phone Number

Health Evaluation

Please answer YES or NO to the following questions, if answered yes; please explain in provided space, if no explanation is given it may result in the delay of starting the program.

History of liver disease or cirrhosis?*

No
Yes

History of bipolar or schizophrenia?*

No
Yes

History of kidney failure or renal disease?*

No
Yes

History of ulcer or stomach bleeding?*

No
Yes

History of colon cancer?*

No
Yes

History of seizures?*

No
Yes

Are you taking medications for tuberculosis?*

No
Yes

Are you actively being treated for cancer?*

No
Yes

Are you taking dilantin?*

No
Yes

Have you had a gastrectomy?*

No
Yes

Do you have a history of polycythemia?*

No
Yes

Are you taking any blood thinners? If so, which medications?*

No
Yes

Please describe your medications.

Are you taking any medications for diabetes? If so, which medications?*

No
Yes

Please describe your medications.

Do you have any known allergies? If so, which allergies?*

No
Yes

Please describe your allergies.

Other Comments

Consent & Patient Agreement

Vitamin / Amino Acid Injections are a class of natural ingredients that play important role in the body’s use of fat. These compounds enhance liver and gallbladder’s role by decreasing fat deposits and speeding up metabolism of fat and its removal. Our formula of Lipotropics has been formulated to enhance your current weight loss efforts i.e. following healthy diet plan, staying well hydrated, and exercising. The amino acids used to make these shots are: B1, B2, B3, B6, B12, MIC, and L-CARNITINE.

Methionine (M) - an amino acid; acts to prevent excess fat build-up in the liver and the body. Is helpful in relieving or preventing fatigue and may have action in the anti-inflammatory process by reducing histamine release.

Inositol (I) - a nutrient belonging to the B vitamin complex; closely associated with choline. It aids in the metabolism of fats and helps reduce blood cholesterol. Inositol participates in the action of serotonin, a neurotransmitter known to control mood and appetite.

Choline (C) - supports the health of the liver by processing and excreting chemical waste products within the body. In addition, it facilitates fat absorption by the cells. It is essential for the health of kidneys and liver.

B12 – an essential vitamin that helps form new healthy cells in the body. It acts as an energy booster, helping increase activity level, improve sleep patterns, and provide relief from allergies and stress.

L- Carnitine - an amino acid that is naturally produced in the body as a primary building block for protein. It helps your body to produce energy, carries fat into cells so it can be burned as fuel, and assists in the reduction of belly fat.

Each patient responds differently to medicine and may respond differently from one treatment to the next. As with all medicines, results are temporary and regular dosing is necessary. The length of time the injectable medication lasts varies in each patient. NO guarantee can be made with regard to the results and length of time it lasts. There are some risks with any treatment. The following is the list of possible risk with injections:

Pain or bruising, redness, bleeding at the injection site (these are usually minimal and dissipate in minimal amount of time).
Some people may experience allergic reaction to the injections.
Stomach upset and urinary problems (urge incontinence), diarrhea.
It has been reported that B12 can cause peripheral vascular thrombosis, itching.
B12 is contraindicated in Leber’s hereditary optic neuritis, as it can cause blindness.
Some patients have reported experiencing joint pain.
Weight loss can be inconsistent from one week to the next.

I had been given the opportunity to have all of my questions answered. I will inform my practitioner of any changes in my medical history, current medications, and/or any changes relevant to this procedure prior any further treatments.

Agreement.*

I agree

I have read and understand the ingredients of the injections being administered to me and I consent to treatment. I further acknowledge that I am taking this injection(s) of my own accord. I agree to release the facility and the medical practitioner from any liability arising from the procedure.

Selfie Verification Upload

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This is used for verification purposes only. Your ID will be purged from our system after verification is complete.

Driver's License ID / Passport ID

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This is used for verification purposes only. Your ID will be purged from our system after verification is complete.

Digital Signature*

Please sign your full name in this box to certify your agreement.

Email

This field is for validation purposes and should be left unchanged.