This information will assist us in assessing your particular problem areas and establishing your medical management. Thank you for your time and patience in completing this form. By signing this form, I am indicating all health history is accurate and correct.

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 practitioners, 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.

 Expected Benefits:
 •          Improved access to medical care by enabling a patient to remain  in his/her   provider's  office (or at a remote site) while the physician obtains test results and consults  from  healthcare practitioners at distant/other sites.

•          More efficient medical evaluation and management.

•          Obtaining expetiise of a distant 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:

•          In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);

•          Delays in medical evaluation and treatment could occur due to deficiencies 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;

 

By signing this form, I understand the following:
 

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

2.      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.

3.       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.

4.      I understand that a variety of alternative methods of medical care may be available to me, and that l may choose one or more of these at any time. My. provider has explained the alternatives to my satisfaction.

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

6.      I understand that it is my duty to inform my provider of electronic interactions regarding my care that I may have with other healthcare providers.

I have read and understand the information provided above regarding telemedicine, have discussed it with my medical provider as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.

 

You will need the following for your telemedicine visit:

Upload a picture of your drivers license
Digital blood pressure cuff with heart rate
Digital weight scale
A strong interent connection
Good lighting for visual examination
Good audio for communication
Minimal to no interruptions

Failure in completion of these items will cause delay or rescheduling of your visit. By signing your name below means that you agree and understand the requirments for a telemedicine appointment.

 

I  hereby authorize Zachary Holbert, FNP-BC to provide medical care to me, including but not limited to the treatment of my weight problem and any coexisting medical conditions. This may involve but not be limited to history taking, in-office testing and physical examination, and additional laboratory testing. I understand that my weight management treatment may consist of specific diet plans, recommendations for behavior modification techniques, and possibly the use of over-the-counter and prescription medications some of which may be used off-label from FDA approval and package inserts.

I understand that if medications are prescribed, especially medications for weight control, their duration of use and prescribed dosage and frequency may exceed or vary with those indicated in the package insert or those set forth by the FDA. These medications have been used safely and successfully in private and academic medical practice with appropriate monitoring for periods and at dosing and frequency regimens exceeding or at variance with those recommended in the product literature. I understand that any medical intervention has associated potential risks and benefits. Risks of this program may include but are not limited to tiredness, weakness, sleep disturbances, headaches, dry mouth, gastrointestinal disturbances, nervousness, psychological problems, high blood pressure, pancreatitis, rapid heartbeat, and heart irregularities. Please also be aware of fetal complications if you become pregnant while using medications. In RARE instances these and other possible risks could be serious or even fatal.

The benefits of successful weight management may include but NOT LIMITED to improved overall health, lower risk of developing serious diseases with at times fatal complications, such as diabetes, breathing problems, joint degeneration, high blood pressure, heart disease, circulation problems, heart attack, and stroke. I understand that I have alternative treatment options, including but not limited to no treatment at all and weight management programs not supervised by a medical provider. I also understand that remaining overweight or obese puts me at greater risk for poor health. Some of the complications that may develop as a consequence of prolonged abnormal body weight are arthritis of the joints, high cholesterol and triglycerides, high blood pressure, insulin resistance/diabetes, vascular disease complicated by stroke, heart attack and abnormal heart rhythms, gallstones, sleep apnea, and sudden death. I understand that these risks may be modest if I am not significantly overweight but will increase with addi-tional weight gain. I, also, understand that the success of my weight management treatment depends on my active participation. The medical provider cannot guarantee or assure treatment success or any definite outcome. I understand that obesity is considered a chronic condition that may require permanent changes. 

OFF LABEL MEDICATION - The U.S. Food and Drug Administration (FDA) has required that drugs used in the United States be both safe and effective. The label information on the container, in the package insert, in published drug references, and in any advertising can indicate a drug’s use only in certain “approved” doses and routes of administration for a particular condition. The use of a drug for a
condition, in a dose, or by a route not listed on the label is considered to be a “nonapproved” or “off-label” use of the drug. Prescribers—based on their knowledge, education, training, experience, and available current information—may use a drug for a use, in a dose, or by a route not indicated in the “approved” labeling if it seems reasonable or appropriate in the prescriber’s professional judgment.

I have read and fully understand this consent form and I realize I should not sign this form if all items have not been satisfactorily explained to me. With my signature I acknowledge that my questions have been answered fully, and that I have been requested to read this form and have been given ample time to understand all its contents.

What is the most important information I should know about phentermine?

Do not use phentermine if you have used an MAO inhibitor such as furazolidone (Furoxone), isocarboxazid (Marplan), phenelzine U [ardil), rasagiline  (Azilect), selegiline (Eldepryl, Emsam, Zelapar), or tranylcyp ·omine (Parnate) in the last 14 days.

A dangerous drug interaction could occur, leading to serious side effects.

Taking phentermine together with other diet medications such as fenf1uramine (Phen­ Fen) or dexfenfluramine (Redux) can cause a rare ·fatal lung disorder called pulmonary hypertension. Do not take phentermine with any ,1ther diet medications without your medical providers advice.

Phentermine may impair your thinking or reactions time. Be careful if you drive or do anything that requires you to be alert. Do not drink while taking phentermine, drinking alcohol can increase certain side effects.

Phentermine is only part of a complete program of treatment that may also include diet, exercise, and weight control. Follow your diet, medication, and exercise routines very closely.

 
Phentermine may be habit-forming and should be used only by the person it was prescribed for. Never share phentermine with another person, especially someone with a history of drug abuse or addiction. Keep track of the amount of medicine used from each new bottle.  Phentermine is a drug of abuse and you should  be aware  if anyone is using your medicine improperly or without a prescription.

Do not stop using phentermine suddenly, or you could have unpleasant withdrawal symptoms. Ask your doctor how to avoid withdrawal symptoms when you stop using phentermine.

You should not take phentermine if you are allergic to it, or if you have:

•         coronary atery disease (hardening of the arteries);

•          heart disease;

•         severe or uncontrolled high blood pressure;

•         overactive thyroid;

•          glaucoma;

•          if you have a history of drug or alcohol abuse; or

•          if you are allergic to other diet pills, amphetamines, stimulants, or cold medications.

 

To make sure you can safely take phentermine, tell your medical provider of all your health conditions.

 

Do not take phenteramine while pregnant or breastfeeding.

 

What are the possible side effects of phentermine?
 
Get emergency medical help if you have any of these signs of an allergic reaction:

hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

 

Call your doctor at once if you have a serious side effect such as:

•          feeling short of breath, even with mild exertion;

•          chest pain, feeling like you might pass out;

•          swelling in your ankles or feet;

•          pounding heartbeats or fluttering in your chest;

•          confusion or iITitability, unusual thoughts or behavior;

•          feelings of extreme happiness or sadness; or

•          dangerously high blood pressure (severe headache, C:lurred vision, buzzing in your ears, anxiety, confusion, chest pain, shortness of breath, uneven heartbeats, seizure).

• feeling restless or hyperactive;

•  headache, dizziness, tremors;

•  sleep problems (insomnia);

• dry mouth or an unpleasant taste in your mouth;

• diarrhea or constipation, upset stomach; or

• increased or decreased interest in sex, impotence.

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

 

What other drugs will affect phentermine?
 

Tell your Medical provider about all other medicines you use, especially:

•  blood pressure medications;

•  insulin or oral diabetes medication; or

• an antidepressant such as citalopram (Celexa), lluoxctine (Prozac, Sarafcm, Symbyax), paroxetine (Paxil). sertraline (Zoloft), and others.

 

This list is not complete and other drugs may interact with phentermine. Tell your medical provider about all medications you use. This includes prescription, over-the-counter, vitamin, and herbal products. Do not start a new medication without telling your provider.

 

Refund Policy

I understand if I fail to show or cancel/reschedule an appointment and
I have not contacted Freedom Medical Care with at least 24 hours notice, I will considered a no show and I will not be refunded the appointment fee. If this occurs, Freedom Medical Care may or may not reschedule at their discretion. 

We schedule appointments on Saturdays and Sundays, if you need a weekday appointment please contact us.