PATIENT CONSENT FOR WEIGHT LOSS THERAPY AND TREATMENT WITH (Renew Weight loss and Med Spa LLC). If you are late or miss your appointment, you may be subject to a $50 fee. Services must be paid for at the time of service.
Health insurance typically does not cover services provided at (Renew Weight loss and Med Spa LLC). If you want to seek insurance reimbursement, we would be happy to provide you itemized invoices that you can submit to your insurance company.
Phentermine and Vyvanse are considered a controlled substance. If prescribed these medications, I agree that I will take my medications as prescribed. I agree to follow my medical providers instructions. I also agree that I will not sell or share my prescriptions to other individuals.
I understand that treatments used at (Renew Weight loss and Med Spa LLC) might not be considered a medical necessity. Treatments rendered are for the purpose of improving your quality of life through hormone restoration, nutritional and supplemental counseling, and weight loss treatment.
I agree that if I am having any side effects or become sick, that I will follow up with my primary care provider or go to an urgent care or emergency department.
I acknowledge that (Renew Weight loss and Med Spa LLC) and weight loss providers are not my primary care provider unless I elect them so. I agree that I will continue with routine care through my primary care provider and notify them of treatments prescribed at (Renew Weight loss and Med Spa LLC).
I understand that there are no refunds for services or products rendered. We cannot accept back used medications once they have been dispensed per state regulation.
I understand that having an appointment with (Renew Weight loss and Med Spa LLC) does not necessarily entitle me to being issued a prescription for hormone replacement, weight loss medication or additional medications. Every individual is different, and it is at the medical providers discretion to issue a prescription.
I understand that I must maintain my follow up appointments to remain on treatment. It is important that lab work is monitored regularly for safety purposes. It is important that (Renew Weight loss and Med Spa LLC) manages my treatment and it is at their discretion to provide
_I acknowledge that I have been advised of the risks and benefits of treatment. I also acknowledge that I have been advised of possible complications and side effects. I understand the risks, benefits, complications, and side effects of treatment.
I am voluntarily requesting treatment with (Renew Weight loss and Med Spa LLC) in regards to weight loss therapy as determined by a mutual decision between myself and the medical provider even if my hormone levels are considered to be in normal range for my age based off of other medical society recommendations and guidelines or if I am just considered overweight and not obese.
I do not hold any medical practitioner of (Renew Weight loss and Med Spa LLC) responsible for performing age-related preventive care. I agree that I will follow up with my primary care provider to obtain these screenings and I hold (Renew Weight loss and Med Spa LLC) harmless if an adverse event occurs during my treatment. I will ensure that my primary care provider provides the results of such screenings to (Renew Weight loss and Med Spa LLC) as this could change the treatment prescribed to me.
