The information provided is a true representation of my current health status. I have read and understand and hereby agree to treatment administered to me, including medications for weight loss. I, the undersigned, have been informed by LAVEEN MEDICAL WEIGHT LOSS & WELLNESS and its affiliates of the hazards and possible consequences involved in treatment by medications, supplements, injections and nonetheless consent to such treatment and agree to hold LAVEEN MEDICAL WEIGHT LOSS & WELLNESS and its affiliates free and harmless of any claims, demands or suits for damage from any injury or complications whatsoever, save negligence, that may results in such treatment. I am also aware there is no guarantee for medication, treatment or results and understand patients may receive medications dispensed by a physician.
WE HAVE THE RIGHT TO REFUSE SERVICE(S)
I agree to pay for all services rendered to me. Should you pursue a chargeback through your credit card company, or otherwise accrue an unpaid balance, you forfeit your right to privacy of the information required to pursue collection and/or legal action will be disclosed in seeking remuneration.
I voluntarily consent to the above treatment and/or procedures and acknowledge the medications may be ordered under my name to be dispensed. I realize that neither the doctor nor any personnel of LAVEEN MEDICAL WEIGHT LOSS & WELLNESS and its affiliates has made any absolute guarantees to me regarding cure or improvement of my condition. I understand that I am free to withdraw my consent and discontinue participation in these procedures at any time.
IF I SUSPECT I COULD BE PREGNANT I UNDERSTAND I SHOULD DISCONTINUE ALL MEDICATIONS, SUPPLEMENTS, or INJECTIONS. PREGNANT OR NURSING MOTHERS SHOULD NOT BE TAKING APPETITE SUPPRESSANTS NOR SEMAGLUTIDE.
**MEDICAL DISCLAIMER:
Pregnancy: weigh risk/ benefit during pregnancy; no human data available; possible risk of fetal harm, incl. teratogenicity and fetal death, base on animal data at
Avoid pregnancy by using effective contraception during tx and for at least 2mo after D/C in female pts
Lactation: weight risk/benefit while breastfeeding; no human data available, though risk of infant harm not expected based on drug properties; no human data available to assess effects on milk production
By signing this document, I have read the above and consent for treatment. (Parent/Guardian sign if Minor) *
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SEMAGLUTIDE WAIVER
Women of childbearing potential are encouraged to use contraception during SEMAGLUTIDE therapy; if pregnancy is desired, stop treatment at least 2 months prior to a planned pregnancy due to its long washout period. ALERT the doctor if you suspect that you are pregnant Semaglutide could present a risk to the fetus.
I recognize the potential risks and benefits of these procedures as described below:
Potential benefits: Restoration of health and the body’s maximum functional capacity without the use of drugs or surgery, relief of pain and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or its progression.
Potential risks: Allergic reactions to prescribed medications, herbs and supplements, side effects of natural medications, inconvenience of lifestyle changes, injury from injections, venipunctures or procedures, tenderness/soreness or bruising from physical treatments.
COMMON SIDE EFFECTS of GLP-1/Semaglutide Constipation, Diarrhea, Dyspepsia, Hypoglycemia, Injection site reaction, Nausea, Vomiting, Abdominal pain, Gastroesophageal reflux (GERD) Dizziness, Eructation, Fatigue, Headache, Anorexia. Not recommended for anyone with severe kidney or pancreas issues*, diabetic retinopathy nor patients with severe GI disease (e.g., Crohn's disease, gastroparesis, inflammatory bowel disease, ulcerative colitis) nor pregnant/breastfeeding. *Semaglutide has rarely caused a very serious (possibly fatal) disease of the pancreas (pancreatitis).
Get medical help right away if you develop symptoms of pancreatitis, including: severe stomach/abdominal pain, nausea/vomiting that doesn't stop. Semaglutide injection may increase the risk that you will develop tumors of the thyroid gland, including medullary thyroid carcinoma (MTC; a type of thyroid cancer). Laboratory animals who were given Semaglutide developed tumors, but it is not known if this medication increases the risk of tumors in humans. Tell your doctor if you or anyone in your family has or has ever had MTC or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2; condition that causes tumors in more than one gland in the body). If so, your doctor will probably tell you not to use Semaglutide injection.
I fully understand and accept responsibility for the situation that certain health risk and/or conditions might arise due to the contraindications of the use of GLP-1. (Parent/Guardian sign if Minor) *
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PHYSICIAN-PATIENT ARBITRATION AGREEMENT
ARTICLE 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered will be determined by submission to arbitration as provided by Arizona law, and not by a lawsuit or resort to court process except as Arizona law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of binding arbitration.
ARTICLE 2: All Claims Must Be Arbitrated: It is the intention of the parties that this agreement shall cover all existing or subsequent claims or controversies whether in tort, contract or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to treatment or services provided or not provided by the below identified physician, medical group or association, their partners, associates, associations, corporations, partnerships, employees, agents, clinics, and/or providers (hereinafter collectively referred to as “Physician”) to a patient, including any spouse or heirs of the patients and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children.
Filing by Physician of any action in any court by the physician to collect any fee from the patients shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against a Physician, including any fee dispute, whether or not the subject of any existing court action shall also be resolved by arbitration.
ARTICLE 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing by U.S. mail, postage prepaid to all parties, describing the claim against Physician, the amount of damages south, and the names, addresses and telephone numbers of the patient and (if applicable) his/her attorney. The parties shall thereafter select an arbitrator who was previously a court judge. Both parties agree the arbitration shall be governed pursuant to Arizona Revised Statutes (ARS) 12-1501-12-1518 and the Federal Arbitration Act (9 U.S.C 1-4) and that they have the absolute right to arbitrate separately the issue of liability and damages upon written request to the arbitrator. The parties shall bear their own costs, fees, and expenses, along with a pro rata share of the neutral arbitrator’s fees and expenses.
ARTICLE 4: Revocation: This agreement may be revoked by written notice delivered to Physician within 30 days of signature and if not revoked will govern all medical services received by the patient.
ARTICLE 5: Severability Provision: In the event any provision(s) of this Agreement is declared void and/or unenforceable, such provision(s) shall be deemed severed there from and the remainder of the Agreement enforced in accordance with Arizona and Federal law. I understand that I have the right to receive a copy of this agreement.
By signing this contract you agree to have any issue of medical malpractice decided by neutral arbitration and give up your right to a jury or court trial. See Article 1. Parent/Guardian if Minor *
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