Laveen

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  • New Patient Form
  • Medical Weight Loss Consent Form
  • Telemedicine Consent Form

New Patient Form

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    New Patient Form


    Medical Weight Loss Consent Form

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      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) *



      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) *



      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 *


      Telemedicine Consent Form

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        TELEMEDICINE PATIENT CONSENT

        PURPOSE: The purpose of “Telemedicine Consent Form” is to get the patient’s consent in order to participate in appointments of telemedicine cares.

        RECORDS: Telecommunications with patients will not be recorded and stored. Patients’ medical information obtained by the diagnosis and analysis can be used anonymously for further improvements in scientific studies.

        TELEMEDICINE INFORMATION: The medical information related to history, records and tests of the patient will be discussed during the telemedicine appointment with video and audio.

        ACCESS: The patient accepts that he/she needs access to PC, laptop, or mobile device and a good internet connection in order to have an efficient telemedicine appointment.

        PATIENT RIGHTS: The patient can withdraw his/her consent at any time and can ask the questions related to telemedicine appointments and technical requirements for telecommunication.



        By signing this form,

        I understand that all the laws that are protecting my privacy of medical history or information are also applied to telemedicine practices.

        I understand that I can withdraw the consent at any time and at that point an in office visit will be required for future treatment; with controlled substances and/or medication adjustments.

        I accept that I authorize health care professionals and use telemedicine for my treatment and diagnosis.

        New Patient Form

          New Patient Form


          Telemedicine Consent Form

            TELEMEDICINE PATIENT CONSENT

            PURPOSE: The purpose of “Telemedicine Consent Form” is to get the patient’s consent in order to participate in appointments of telemedicine cares.

            RECORDS: Telecommunications with patients will not be recorded and stored. Patients’ medical information obtained by the diagnosis and analysis can be used anonymously for further improvements in scientific studies.

            TELEMEDICINE INFORMATION: The medical information related to history, records and tests of the patient will be discussed during the telemedicine appointment with video and audio.

            ACCESS: The patient accepts that he/she needs access to PC, laptop, or mobile device and a good internet connection in order to have an efficient telemedicine appointment.

            PATIENT RIGHTS: The patient can withdraw his/her consent at any time and can ask the questions related to telemedicine appointments and technical requirements for telecommunication.



            By signing this form,

            I understand that all the laws that are protecting my privacy of medical history or information are also applied to telemedicine practices.

            I understand that I can withdraw the consent at any time and at that point an in office visit will be required for future treatment; with controlled substances and/or medication adjustments.

            I accept that I authorize health care professionals and use telemedicine for my treatment and diagnosis.

              HCG WEIGHT LOSS PROGRAM

              I request injections of hCG along with strict dietary restrictions for the purpose of weight loss. I understand that as part of the program, I will be given a limited physical orientation to the program with supporting materials, and I will be instructed on how to administer the injections myself. I understand that initial blood tests will be necessary to rule out any conditions that would disqualify me from the program. I will obtain these from my own physician or have them ordered through Laveen Medical Weight Loss & Wellness. I understand hCG is not FDA approved for weight loss as this application is considered “off-label use.” I understand there is no medical evidence to support the use of hCG for this purpose. I agree that I am and will be under the care of another medical provider for all other conditions.

              Medical Providers at Laveen Medical Weight Loss & Wellness can work in conjunction with, but cannot replace, my regular primary care physicians, such as general practitioners or other specialists in family medicine or internal medicine. I understand Medical Providers at Laveen Medical Weight Loss & Wellness can only prescribe hCG and medication necessary for this treatment and all other health matters should be through my regular physician(s). Prior to my treatment, I have fully disclosed any medical conditions or diseases such as trying to get pregnant, pregnancy, breastfeeding, history of gallbladder disease, diabetes, autoimmune diseases, HIV, heart disease, liver disease, kidney disease, uncontrolled high blood pressure, seizure disorders, blood disorder (anemia, thalassemia, hemophilia, etc.) emphysema or asthma, and any history of stroke or cancer. These contraindications have been fully discussed with me. If I fail to disclose any medical condition that I have, I release the doctor and facility from any liability associated with this procedure.


              While hCG is generally free of negative side effects, there is the possibility of the following: • Ovarian Hyper-stimulation Syndrome (OHSS) – which is a life-threatening condition • Arterial Thromboembolism – another potentially life-threatening condition • Blood clots • Risk of pregnancy and multiple pregnancies (twins, triplets, quadruplets, etc.) • Abnormal enlargement of breasts in men (gynecomastia) • Over stimulation of the ovaries causing production of many ova (eggs) in women • Acne • Tiredness • Changes in mood • Irritation or skin rash in area of use • Excessive fluid retention in the body tissues, resulting in swelling (edema) • Hair loss • Prostate hypertrophy • Difficulty breathing • Collapse • Death • I understand hCG treatments may involve these risks and other unknown risks


              I understand that use of hCG is absolutely contraindicated during pregnancy and breastfeeding. I understand that it is my responsibility to inform the Medical Providers at Laveen Medical Weight Loss Wellness if I am pregnant, if I am trying to become pregnant or if I become pregnant during the course of these treatments.

              I understand that hCG is used in infertility treatments, and therefore I have an increased chance of pregnancy while on hCG. Multiple birth control methods should be used while on hCG. However, hCG is contraindicated for women using IUD for birth control.


              I agree to immediately report any problems that might occur to my medical provider during the treatment program. I further understand that not complying with the dosage recommendations and dietary restrictions could increase risks and alter my results from the program. If I do not follow these recommendations and restrictions, I agree to release Medical Providers at Laveen Medical Weight Loss & Wellness and facility from any liability arising as a result of this.

              I understand that I may quit the program at any time. While adverse side effects or complications are not expected, in the event that an illness does occur, I understand that I need to contact Medical Providers at Laveen Medical Weight Loss & Wellness immediately. If I experience an emergency situation, I understand that I need to go to an emergency facility.


              I understand that if there are any changes in my medical history or there are any changes in my medications or any other changes relevant to this procedure, I will advise Medical Providers at Laveen Medical Weight Loss & Wellness at that time.


              All my questions have been addressed to my satisfaction. I agree to release the Medical Providers and Laveen Medical Weight Loss & Wellness from any liability associated with this procedure. In the event a dispute arises over the outcome of the procedure, I consent solely to arbitration as a legal means of settlement.