Med-Fit Virtual Program Parental Consent Forms MED-FIT PATIENT PROGRAM CONSENT FORM
We want you to know...
When you decided to learn more about managing your weight, you took an important step toward improving your health. Your Med-Fit medical provider and your hand-selected team will help you develop comprehensive weight management skills while you lose a meaningful amount of weight.
Your Role...
Your success will depend on your commitment to understanding and fulfilling your obligations in the course of treatment. You must be willing to:
Provide honest and complete answers to questions about your health, weight problem, eating habits, and lifestyle patterns so that we can better understand how to help you.
Devote the time needed to complete and comply with the course of treatment Med-Fit has outlined for you, including assessment, program layout, and long-term management phases.
Work with Your Med-Fit medical provider and the Med-Fit team who may participate in helping you manage your weight loss, including tracking meals and activity daily, attending your sessions regularly, and following your diet and exercise prescription.
Allow your Med-Fit medical provider to share information with your primary care physician. Make and keep follow-up appointments with your Med-Fit medical provider. However, it is integral that you continue to follow up with your primary care or specialty care providers as designated by your healthcare team during your course of treatment at Med-Fit. If you do not have a personal primary care physician, we strongly recommend that you find one before you and your Med-Fit medical provider begin working together. Your Med-Fit medical provider will not act as a primary care physician.
Follow your exercise and nutrition program within the guidelines given to you by the Med-Fit team. It is vitally important for you to advise the clinic staff of ANY concerns, problems, complaints, symptoms, or questions even if you think it is not important, so your Med-Fit medical provider can determine if you should be seen more often. Keeping the clinic informed of any questions or symptoms, affords the best chance of intervening before a problem becomes serious.
Potential Benefits...
Medically-significant weight loss can:
Lower your blood pressure, reducing the risks of hypertension*
Lower your cholesterol, reducing the risks of heart and vascular disease*
Lower blood sugar, reducing the risks associated with diabetes*
Increasing activity level can favorably affect the above conditions and has the additional benefit of helping you sustain weight loss.
Weight loss and increased activity provide important psychological and social benefits as well.
*If you are currently taking medications for one or more of these conditions, dosages may need to be adjusted as your overall health improves. You agree to see your physician as needed to have your need for these medications reassessed*.
Possible side effects...
The possibility always exists in medicine that the combination of any significant disease with methods employed for its treatment may lead to previously unobserved or unexpected ill effects, including death. Should one or more of these conditions occur, additional medical or surgical treatment may be necessary. Also, it is conceivable that other side effects could occur that have not been observed to date. Reduced Weight - When you reduce the number of calories you eat to a level lower than the number of calories your body uses in a day, you lose weight. In addition, your body makes some other adjustments in physiology. Some of these are responsible, in some participants, for rapid improvements in blood pressure and blood sugar; other adjustments may be experienced as temporary side effects or discomforts. These may include an initial loss of body fluid through increased urination, momentary dizziness, a reduced metabolic rate or metabolism, sensitivity to cold, a slower heart rate, dry skin, fatigue, diarrhea or constipation, bad breath, muscle cramps, a change in menstrual pattern, dry and brittle hair or hair loss. These responses are temporary and resolve when calories are increased after the period of weight loss. Reduced Potassium Levels - The calorie level you will be consuming is likely going to be a significant decrease compared to what you are used to, and it is important that you consume the calories that have been prescribed in your diet to minimize side effects. Failure to consume all of the food, fluids, and nutritional products or taking a diuretic medication (water pill) may cause low blood potassium levels or deficiencies in other key nutrients. Low potassium levels can cause serious heart irregularities. When someone has been on a reduced-calorie diet, a rapid increase in calorie intake, especially overeating or binge eating, can be associated with bloating, fluid retention, disturbances in salt and mineral balance, or gallbladder attacks and abdominal pain. For these reasons, following the diet carefully and following the gradual increase in calories after weight loss is essential.
Gallstones - Overweight people develop gallstones at a rate higher than normal-weight individuals. The occurrence of symptomatic gallstones (pain, diagnosed stones and/or surgery) in individuals 30% or more over desirable body weight (50 pounds or more overweight) not undergoing current treatment for obesity is estimated to be 1 in 100 annually, and for individuals who are 20-30% overweight, about one-half that rate, or 1 in 200 annually. It is possible to have gallstones and not know it. One study of individuals entering a weight loss program showed that as many as 1 in 10 had “silent gallstones at the onset.” As body weight and age increase, so do the chance of developing gallstones. These chances double for women, women using estrogen, and smokers. Losing weight - especially rapidly - may increase the chances of developing stones or sludge and/or increasing the size of existing stones within the gallbladder.
Should any symptoms develop (the most common are fever, nausea, and cramping pain in the right upper abdomen, or if you know or suspect that you may already have gallstones), let your physician and healthcare professional know immediately. Gallbladder problems may require medication or surgery to remove the gallbladder, and less commonly, may be associated with more serious complications of inflammation of the pancreas or even death. A drug (Ursodiol) is currently available that may help prevent gallstone formation during rapid weight loss. You may wish to discuss Ursodiol with your primary care physician for more information.
Pancreatitis - Pancreatitis, an infection in the bile ducts, may be associated with the presence of gallstones and the development of sludge or obstruction in the bile ducts. The symptoms of pancreatitis include pain in
the left upper abdominal area, nausea, and fever. Pancreatitis may be precipitated by binge-eating or consuming a large meal after a period of dieting.
Also associated with pancreatitis are long-term abuse of alcohol and the use of certain medication and increased age. Pancreatitis may require surgery and may be associated with more serious complications and death.
Pregnancy - If you become pregnant, report this to your healthcare professional and physician immediately. Your diet must be changed promptly to avoid further weight loss because a restricted diet could be damaging for the developing fetus. You must take precautions to avoid becoming pregnant during weight loss.
Binge Eating Disorder - Binge eating disorder is defined as the habitual, uncontrolled consumption of a large amount of food in a short period. Participation in a calorically restricted diet has been shown in one study to increase binge eating episodes temporarily. Several other studies demonstrated reduced episodes of binge eating following a calorie deficit and portion-controlled diet. Extended binge eating episodes are associated with weight gain.
The risk of weight regain.
Obesity is a chronic condition, and the majority of overweight individuals who lose weight tend to regain all or some of it over time. Factors that favor maintaining a reduced body weight include regular physical activity, adherence to a restricted-calorie, low-fat diet, and planning a strategy for coping with weight regain before it occurs.
Successful treatment may take months or even years. Medical studies of calorie deficit/portioned-controlled diets have shown varying results for a percentage of patients who maintain weight loss. Additionally, if you have had fluctuations in your weight in the past, it may be more difficult to maintain the weight you lose during and after this program.
Sudden Death.
Patients with morbid obesity, particularly those with serious hypertension, coronary artery disease, or diabetes mellitus, have a statistically higher chance of suffering sudden death when compared to normal-weight people without such medical problems. Rare instances of sudden death have occurred while obese patients were undergoing medically supervised weight reduction, though no cause and effect relationship with the diet has been established. The possibility cannot be excluded that some undefined or unknown factor in the treatment program could increase this risk in already medically vulnerable patients.
I, the undersigned, have reviewed the information included in the Patient Program Consent Form with my healthcare professional or my physician, and have had an opportunity to ask questions and have them answered to my satisfaction.
POLICIES AND PROCEDURES (If Applicable)
Virtual Group Classes and Virtual/Phone 1:1 Sessions
Zoom meeting is the preferred method of communication for accountability, nutrition, and fitness sessions. E mail is also a method of communication because it creates a reference trail. Telephone/Zoom meetings should always be planned to avoid any scheduling conflicts.
Communications
The Med-Fit staff and coaches want you to feel supported at all times. When it comes to communicating with your coaches, they are available during office hours only, and please allow a response time of 24 hrs or the next business day.
Progress Reports
The foundation of the “virtual” process is communication between the patient and Med-Fit team members, so it is essential to maintain consistent communication with your team, regarding weight progress, obstacles, and successes on a weekly or bi-weekly basis.
Programs/Software
Med-Fit, PLLC uses Healthie, Google Docs and Drive (word processing, cloud storage, and patient program management). Most of these programs are suitable for collaborating with patients, and patients will never incur any fees related to my use of these programs.
Privacy & Confidentiality
Privacy and client confidentiality are crucial to Med-Fit, PLLC. Client information will never be disclosed or sold to third parties or made public without the client’s permission unless Med-Fit is legally obligated to do so. A client’s data and information will be kept confidential.
Late Arrivals
Patients are allowed a 10 minute grace period. If you are more than 10 minutes late you automatically forfeit your appointment for that week. We will reschedule you per your program layout. Please provide us the courtesy of sending an email to support@denverweightlossclinic.com (mailto:support@denverweightlossclinic.com) in advance if you are going to be running late to your appointment. All appointments will begin at the scheduled appointment time.
Appointment Cancellations
24 hours notice is required for all canceled appointments. PLEASE email support@denverweightlossclinic.com (mailto:support@denverweightlossclinic.com) if you need to cancel.
Missed Appointments
After three “No call/No show” appointments, any additional missed appointments without prior 24 hour notification will be forfeited. **Each missed appointment is recorded in your records. You are responsible to utilize all of your services before your expiration date.**
Program Duration
Your program has a specified duration and expiration date. It is your responsibility to ensure that you utilized all services during the allotted program time. If you are unable to continue your scheduled program appointments and services or need to make adjustments to the duration of your program, then you must inform the Med-Fit staff as soon as possible. If you do not use all of your services within the allotted program time, then they are considered a forfeit. Your expiration date is included in your welcome email and program layout via Healthie and can be provided by a Med-Fit staff member at any time.

Termination Policy
Med-Fit, PLLC has the right to terminate any patient program and/or end any patient relationship at its discretion upon notice to you. The following are considered a reason to terminate a patient from Med-Fit Medical Weight Loss.:
1. Misuse, abuse and/or duplication of prescription medications
2. The physician determines he/she cannot provide continued, effective care.
3. Threat of legal action against Med-Fit Medical Weight Loss physicians and employees. 4. Chronically not showing up for appointments.
5. Failure of a patient to comply with the physician’s orders preventing the physician from providing adequate medical care.
6. Repeated failure to pay reasonable medical bills and services.
7. Ongoing rude, disruptive, or unreasonably demanding behavior.
8. Falsifying or providing misleading medical history.
9. Seductive behavior toward physicians or staff.
10. Discharge will be immediate for any threatening behavior (physical or verbal) or any implication of harm to any Med-Fit staff member.

CANCELLATION AND POLICIES:
I understand the program involves a course of treatments. The fee structure has been fully explained and I understand that I am required to pay for the full course of the program. I understand that I am agreeing to pay in full for the program whether it be in full or have agreed to a payment arrangement with Med-Fit, PLLC.
No Refunds...
I understand Med-Fit, PLLC abides by a strict, no refund policy. By accepting the terms of this agreement, you agree and understand that you are foregoing the right to claim any refund of fees paid for access and use of the programs offered by Med-Fit, PLLC. You further acknowledge that in accepting the terms of this agreement, you agree that you will not request a refund.
If delinquency of payment occurs Med-Fit, PLLC will follow the Collection Cost terms.

COLLECTION COSTS:
I understand that in the event of any default, Med-Fit, PLLC may declare the entire unpaid balance to be immediately due and payable, and if Med-Fit, PLLC then assigns this agreement to a collection agency for recovery, the patient is responsible for up to 30% of the unpaid principal balance as a reasonable cost of collection.

ATTORNEY FEES / COURT COSTS:
I understand that any lawsuit over the terms of this agreement shall be brought within the courts of Colorado and governed by the laws of that state. Accordingly, the parties hereby subject themselves to the jurisdiction of those courts. Should such a dispute result in any term being declared contrary to those laws, the remaining terms shall still be binding. The losing party will pay all reasonable and necessary costs (including attorney fees) of any lawsuit to enforce this agreement.


LATE FEES:
I understand that if an installment is not paid within five (5) days after the due date thereof that a $15 charge will be assessed for each delinquent day. This charge will be assessed until a payment is 30 days past due. At that point, the remaining balance will be sent to collections, including accrued late fees. Late fees will not accrue past the maximum amount of $390.00.

CANCELLATION AND POLICIES:
I understand the program involves a course of treatments. The fee structure has been fully explained and I understand that I am required to pay for the full course of the program.
NO REFUNDS: Med-Fit, PLLC abides by a strict no refund policy. By accepting the terms of this agreement, you agree and understand that you are foregoing the right to claim any refund of fees paid for access and use of the Programs offered by Med-Fit, PLLC. You further acknowledge that in accepting the terms of this agreement, you agree that you will not request a refund.

INSUFFICIENT FUNDS POLICY:
I understand insufficient payment in the form of an EFT (electronic funds transfer) or check, will result in a service fee of $20.00. The remaining balance will be accepted in the form of a cashier’s check, made payable to “Med-Fit Medical Weight Loss Clinic”.
MED-FIT PROGRAM DISCLAIMER
Success Not Guaranteed: you agree and acknowledge that Med-Fit, PLLC provides medically supervised weight management services and coaching and guarantees no specific results. Upon signing this contract, you agree and take full responsibility for your success. You also acknowledge that each individual’s success and weight loss results are based on their commitment level, motivation, and unique individual metabolism and body type. You agree that you are responsible for the successful outcome of your chosen program and that Med-Fit, PLLC is not held responsible for any lack of weight loss and/or weight gain that occurs with any participation related to Med-Fit.
Limited Liability: In no event will Med-Fit, PLLC be liable to you or any party related to you for any damages for weight gain or lack of weight loss.
Commitment to the Program: By accepting the terms of the agreement, you commit and agree to show up to your appointments, follow the plans as instructed, and implement the teachings of the program to the best of your ability. You also acknowledge that creating significant weight loss requires a significant amount of effort, commitment, and compliance and that you are prepared to do so.
Indemnification: YOU will, at your own expense, defend, indemnify, and hold Med-Fit, PLLC, its agents, and employees harmless from any and all claims, actions, liabilities, injuries, damages, losses, grants, costs, and expenses, including attorney fees, arising out of or in connection with any use of the Program(s) of this Agreement.
I agree to be bound by the terms and conditions of specific program
CONSENT TO EMAIL OR TEXT USAGE FOR APPOINTMENT REMINDERS AND OTHER HEALTHCARE COMMUNICATIONS
I authorize the receipt of email/text messages for appointment reminders and any general correspondence to the following:
The Practice does not charge for this service, but standard text messaging rates may apply as provided in your wireless plan (contact your carrier for pricing plans and details).
To help ensure our customers’ data is kept private and secure, Healthie undergoes a rigorous accreditation process that evaluates our policies, security controls, IT procedures, data centers, disaster recovery, software development life cycle, customer service, staff training, human resource management, and more.

I agree to the program terms stated above and I confirm that I received a copy of this document.

By agreeing I certify that the information is true and correct. Further, I agree to be bound by the terms and conditions of the authorization and release.