Please read this waiver and sign and date below.

1.Oral Appetite Suppressants 
You are about to begin a weight loss program using medications that have been approved individually by the FDA. The manufacturer's insert recommends these drugs for short-term use in the treatment of weight loss. However it is important to note that sometimes the doses, drug combination and duration of treatments are "off label" which means that it is legal and perfectly acceptable for doctors to use these therapies according to their best judgment and medical experience. While potential exists for class IV drugs, a four year study showed NO abuse or dependence. We treat overweight and obesity as chronic illnesses, which sometimes require multi-drug therapy and long-term maintenance. This is similar to treating high blood pressure, diabetes and other chronic conditions which are "controlled" but not "cured". You may gain weight if the medication is discontinued. These medications should NOT be taken if you have untreated angina (chest pain), glaucoma, untreated hypertension (high blood pressure), hyperthyroid disease, or an allergy to sympathomimetic medications (such as Sudafed) or if you are pregnant, can become pregnant, or are breastfeeding. There is the possibility of certain side effects including, but not limited to; dry mouth, insomnia, dizziness, nervousness, diarrhea or constipation, fast or irregular heart beat. These side effects are usually mild and disappear within the first 2-4 weeks as your body adjusts to the medication. Please inform your physician if you experience any uncomfortable or persistent side effects. Inform your physician if you are allergic to Phentermine or any other medications; what other medications you are currently taking (prescription or non-prescription); If you have ever suffered from a heart condition, high-blood pressure, arteriosclerosis, overactive thyroid, diabetes, glaucoma, or have a history of drug abuse.

2. Compounded Medications: Semaglutide and Tirzepatide
Semaglutide and Tirzepatide are FDA Approved for diabetes and weight loss. Semaglutide and Tirzepatide are synthetic analogs of the human glucagon-like peptide-1 (GLP-1) hormone. These medications act as GLP-1 receptor agonists, which help regulate blood glucose levels, slow gastric emptying, and increase satiety, thereby contributing to weight loss. Semaglutide and Tirzepatide are used by our providers to treat patients who are overweight–high risk personal or family history of comorbid diseases (hypertension, Obesity, High cholesterol) or patients who are obese. You may gain weight if the medication is discontinued.

These medications combined with routine guidance from our providers, along with the recommended dietary changes, routine exercise, can help patients achieve gradual weight loss. These Treatments also have many possible side effects however they are generally well tolerated by most patients. Additionally, the side effects tend to improve over time with usage and sometimes can also be prevented by limiting foods that commonly trigger these side effects. Most common triggers include high fat, high sugar, and alcohol containing foods. If you notice any side effects, let your provider know. If you notice severe, life threatening, intolerable side effects, seek emergency help.

I acknowledge that there are potential risks and side effects associated with the use of Semaglutide and Tirzepatide. Common side effects include but are not limited to: nausea, vomiting, diarrhea, constipation, abdominal pain or distension, gas, gastroesophageal reflus disease (GERD), decreased appetite, headache, dizziness, hypotension, heart rate increases, fatigue, hair loss, and injection site reactions such as pain or redness Rare but serious side effects may include: pancreatitis, gallbladder disease, hypoglycemia (low blood sugar), kidney problems,  and allergic reactions including anaphylaxis. GLP-1s MAY DECREASE Effect of Oral Birth control. Barrier Methods are recommended to decrease chances of pregnancy within two months of using GLP1-s or changing of your dosages. Do Not Take If: Allergic to GLP-1 agents such as (Trulicity®, Ozempic®, Saxenda®, Rybelsus®, Victoza®, or Wegovy®. semaglutide, dulaglutide, tirzepatide), Pregnant or planning to get pregnant in next 2 months, breastfeeding or planning to breast feed, personal or family history of medullary thyroid cancer or multiple endocrine neoplasia syndrome type two, suicidality history or active suicidal ideation, you have a history of pancreatitis, you are diabetic and/or taking any medications related to lowering your blood sugar levels without speaking to your doctor as dosage adjustments may be necessary, . I understand that these medications may not be appropriate for all patients, and the Physician will evaluate my medical history and current health status before prescribing these medications.

I understand the prescription will come from a compounding pharmacy or facility and that compounded drugs, by definition, are not FDA approved. Compounded products are exempt from FDA approval and no claims are made to the safety and efficacy of any compounded product for an indication or specific use. The FDA does not review compounded medications for safety or effectiveness before they reach patients. I have been told that the preparation of the compound is in accordance with either USP or cGMP requirements, meaning that the pharmacy or facility itself is either Board of Pharmacy or FDA monitored along with third party testing of the medication itself. Administration of the compounded formulations is be based upon the professional judgment of the licensed health care provider after considering the patient’s unique medical conditions and factors including body weight, size and overall health status. No liability attaches in any way to any actual or alleged injury to any person or any damage to any tangible property if the compounded product is used beyond the scope as prescribed by your physician.

3. Vitamin B12 and Lipotropic Injections
Vitamin B12 is vital for proper bodily functions, including brain function and the production of DNA and red blood cells. It may be administered through injections, especially for individuals who have difficulty absorbing this vitamin. Lipotropic Injections contain compounds that assist in the breakdown of fat in the liver, aiding in weight loss and supporting overall liver function.

I understand and acknowledge that there are potential risks, side effects, and benefits associated with Vitamin B12 and Lipotropic Injections. Common side effects may include: mild pain, redness, or irritation at the injection site, mild diarrhea, and swelling sensation in the body. Rare but serious side effects may include: Unusual weakness, numbness, or tingling of the arms or legs, and allergic reactions, symptoms of which may include difficulty breathing, swelling of face/lips/tongue/throat, rash, and severe dizziness.

4. Alternatives to Treatment
I understand that the purpose of this medical weight loss program is to assist me in achieving my weight loss goals and maintaining a healthy weight through the use of medications, lifestyle modifications, and dietary guidance. I acknowledge that there are alternative treatments and weight loss methods available, including but not limited to: diet and exercise programs, behavioral therapy, other weight loss medications and bariatric surgery. I understand that I am under no obligation to participate in this weight loss program and that I may choose an alternative method at any time.

5. General
While receiving treatment at Rivas, be sure to let all of your medical providers know ALL of your medical history, medication changes, supplements, pregnancy status or plans to get pregnant, breastfeeding status, recent hospitalizations, upcoming procedures, or changes in health–at each visit. I acknowledge that I have read the above information. I do not have any of the above mentioned conditions that would make these treatments contraindicated. I will inform all of my medical providers at Rivas as well as my entire medical team outside of Rivas Medical Weight Loss, of all of my medication usage, new treatments, planned surgeries, pregnancy and overall changes in health status. I am aware that other unexpected risks or complications may occur and that no guarantees or promises have been made to me concerning the results of treatment. I also understand that during the course of the proposed treatment, unforeseen conditions may be revealed requiring performance of additional procedures to be covered at my own expense and will not hold Rivas Medical Weight Loss accountable for additional fees. I have read and understand the information provided in this disclosure and consent form. I understand I will have had the opportunity to ask any questions and to receive answers about this weight loss program.  I understand that the medications are dispensed for my convenience and I am free to choose a written prescription in lieu of dispensing. Prescription drugs may be purchased if a pharmacy is not conveniently available to me (the patient).  I have the freedom to bring the prescription to a pharmacy of my choice. The determination that a pharmacy is not available to me (the patient) is made solely by me (the patient). I hereby agree to the treatment plan of Rivas Medical Weight Loss and I understand that the outcome cannot be guaranteed.

 

6. No Insurance Accepted
You acknowledge and understand that Rivas Medical Weight Loss does not participate with any health insurance companies or plans, and has no contractual obligations with such. You agree that you are responsible for any payment obligations which may arise from the services received.

 Prices may vary and change. My charge will include in person and via communication through other media outside of the office setting), supplies, and medication. Rivas Medical Weight Loss may change the pharmacy based on several factors (availability, shipping time, cost). The Practice will tell you as this happens.

7. Confidentiality
I understand that my medical information related to this weight loss program will be kept confidential and will only be shared with my healthcare team and other authorized personnel as required by law.

8. Consent
I have read this form in is entirety. It has been explained to me. I have had the opportunity to ask questions and have all my questions answered. I fully understand the above information and have no further questions. If you have any questions as to the risk or hazards of this treatment, or any questions whatsoever concerning the proposed treatment or other possible treatments, ask the staff now before signing this consent form. By signing this form, I voluntarily give my consent to treatment and agree to the risks.

Please read this waiver and sign and date below.

This form confirms your agreement and understanding regarding the use of telehealth services and electronic communications provided by Rivas Medical Weight Loss
 

1. ACKNOWLEDGEMENT OF TELEHEALTH SERVICES

Telehealth involves the delivery of healthcare services, including medical advice, healthcare information, and other services, using interactive audio, video, and/or data communications. This means that you, the patient, and your healthcare provider may not be in the same physical location during your healthcare services.

By signing this waiver, you acknowledge and agree to the following:

a. You understand that while telehealth services have been found to be effective in a wide range of medical situations, no specific results can be guaranteed or assured.

b. You understand that telehealth services may involve electronic communication of your personal medical information also called protected health information (PHI) to other healthcare practitioners who may be located in other areas, including out of state. PHI includes, but is not limited to, individually identifiable health information; medical history; diagnoses; communications to and from  other health care provider(s).

 

c. You understand that PHI may be lost due to technical failures, cyber intrusion or other issues disrupting the telehealth visit or causing delays in response from the healthcare provider.

 

d. You understand that PHI obtained during the telehealth visit will not be disclosed to others without your consent unless permitted by applicable law and in accordance with the Rivas Medical Weight Loss Notice of Privacy Practices[mr1] [mr2] . 

  

d. You understand that you have the right to withhold or withdraw your consent to the use of telehealth services at any time, without affecting your right to future care or treatment.

f. You agree that your healthcare provider will determine whether your condition is appropriate for telehealth and you acknowledge that the healthcare provider may recommend an in-person visit in lieu of, or in addition to, the telehealth visit.

2. ACKNOWLEDGEMENT OF ELECTRONIC COMMUNICATION

By signing this waiver, you consent to the use of electronic communication (such as email, text messages, video conferencing, and online patient portal systems) in the course of your care.

You acknowledge and understand:

a. The use of electronic communication to discuss sensitive medical information does carry some level of risk. While the provider uses secure, encrypted email and messaging systems, these electronic communications can be intercepted. You assume these risks and holds the healthcare provider harmless from any claims arising out of the use of telehealth to conduct the visit.

b. You understand that you are responsible for providing the provider with your most current and accurate contact information.

c. You have the right to revoke your consent to the use of electronic communication at any time by written communication to the provider.

By signing this waiver, you represent that you have read and understood the information provided above, you have been afforded the opportunity to ask questions about the information presented within this Telehealth Consent Form and all of your questions have been answered, and you consent to the use of telehealth services and electronic communication in your medical care.

Please read this waiver and sign below.

$50 “No Show” Fee and Cancellation Policy for Appointments.
At Rivas Medical Weight Loss, our goal is to provide quality weight loss management. In order to do so, we have had to implement an appointment/cancellation policy. This policy allows us to better utilize available appointments for patients in need of treatment.

Cancellation/No Show Policy

We understand that there are times when you must miss an appointment due to emergencies or obligations. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise when another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly “full” appointment book.

A “no show” is someone who misses an appointment without canceling it within 24 hours in advance. Patients who fail to show up for their scheduled appointment or did not notify the office within 24 hours of their scheduled appointment time, shall be subject to a “No Show/Cancellation” fee of $25.00. In the event of an emergency, and prior notice could not be given, consideration will be given, and a one-time exception may be granted.

How to Cancel Your Appointment

Please call our office at any time. If you receive the answering machine, please leave a message with your full name, phone number, appointment time and date, and when you would like to reschedule your appointment.

Late Policy

Please Arrive 10 min Prior to your appointment. We understand that delays can happen, however, we must try to keep the other patients and doctors on time. If you are running late, please notify the office. We may have to reschedule your appointment if you are not present inside of the clinic within 10 min of an office closure (Lunch Break, Office Closing TimesVary by location, Posted online).