MED-FIT, PLLC MEDICATION 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 on site (virtually) 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 on site to share information with your primary care physician. Make and keep follow-up appointments with your Med-Fit medical provider. If you have a primary care doctor and/or specialty care provider, we encourage you to let them know we will be contributing medical providers in your healthcare so that we are all working together on the same page.
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 Med-Fit medical providers 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*.

Compounded Semaglutide and Tirzepatide (if available or applicable) As part of our commitment to innovative treatments in weight management, Med-Fit, PLLC may provide access to compounded Semaglutide and Tirzepatide, depending on availability and individual suitability as determined by medical evaluations. It is important to note that while FDA-approved versions of these medications exist, the compounded forms used here are not FDA-approved. These treatments are prepared in specialized pharmacies to meet specific dosage needs not available in commercially manufactured forms and are used under strict medical supervision. Below are potential side effects associated with these medications:
Common Side Effects:
Nausea: Often mild and diminishes over time.
Diarrhea and Constipation: Changes in bowel habits that usually resolve as your body adjusts to the medication.
Decreased Appetite: Many patients experience a reduction in hunger, aiding in weight loss.
Injection Site Reactions: Some may notice redness, swelling, or irritation at the site of injection.
Less Common Side Effects:
Gastrointestinal Distress: Includes vomiting, stomach upset, or abdominal pain.
Headache and Dizziness: Typically transient.
Fatigue: Feeling unusually tired, often resolving with continued treatment.
Serious Side Effects:
Pancreatitis: Severe abdominal pain that may radiate to the back, nausea, and vomiting.
Thyroid Tumors: Patients with a personal or family history of thyroid cancer or those with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2) should avoid using these medications.
Gallbladder Disease: Increased risk with rapid weight loss.
Hypoglycemia: Especially in patients with type 2 diabetes using other diabetes medications.
Kidney Issues: Important to stay hydrated to avoid complications.
Precautions:
Inform your healthcare provider of any medications you are taking as interactions may occur.
Regular follow-ups will be scheduled to monitor your health and response to the medication.
Discontinue use and inform your healthcare provider immediately if severe side effects occur.
By choosing to use compounded Semaglutide or Tirzepatide as part of your weight management program, you understand the risks and benefits and agree to closely monitor your health in coordination with your Med-Fit medical provider.

POLICIES AND PROCEDURES Virtual Group Classes and Virtual/Phone 1:1 Sessions Zoom meeting is the preferred method of communication for accountability, nutrition 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 hours 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 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 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.
Program Duration Your program has a specified duration and expiration date. It is your responsibility to ensure that you utilize 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 program 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.
Physician Care Guidelines Med-Fit, PLLC is a medically supervised establishment with specific guidelines that need to be met to best serve you. When taking any appetite suppressant, you are required to schedule a virtual appointment with a Med-Fit medical provider, once every 3 months - no exceptions. At any time you have a concern, please contact a member of your Med-Fit team so they can schedule a follow-up visit with your Med-Fit medical provider.
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.:
Misuse, abuse, and/or duplication of prescription medications
The physician determines he/she cannot provide continued, effective care.
Threat of legal action against Med-Fit Medical Weight Loss physicians and employees.
Chronically not showing up for appointments.
Failure of a patient to comply with the physician’s orders preventing the physician from providing adequate medical care.
Repeated failure to pay reasonable medical bills and services.
Ongoing rude, disruptive, or unreasonably demanding behavior.
Falsifying or providing misleading medical history.
Seductive behavior toward physicians or staff.
Discharge will be immediate for any threatening behavior (physical or verbal) or any implication of harm to any Med-Fit staff member.
Additional Charges
Please note, patients who are given the option and agree to start medication prescribed by your Med-Fit medical provider, understand that there is an additional charge from the pharmacy when you pick up your prescription. The additional charge is based on your specific insurance coverage and it is your responsibility. For coupons visit GoodRx.com
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.
If payment made via credit card is deemed insufficient, the patient is responsible for contacting Med-Fit, PLLC and amend the payment. Our staff will make a total of 3 attempts to reach the patient within a 10 business day time frame, to amend the payment method If payment is not amended or an arrangement is not made within 30 days, Med-Fit, PLLC will have no choice but to send the account to collections. Thank you for your consideration of these policies. We are glad that you have chosen Med-Fit Medical Weight Loss for your weight loss journey.
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.
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 provided 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.
MEDICATION PROGRAM LAYOUT Medication Program 3 or 6 month Initial contract - Initial program fee Medication called in once a month for a total of 3 or 6 months months (per 30 day refill) Virtual Check-in Form 1 month after starting medication Email support access with questions 1 Med-Fit meal plan Labs at an additional cost (optional) If interested in continuing a medication program after your initial 3 or 6 months, please reach out to Nallely, our Patient Assistant Coordinator, for pricing information. Prescription refill requests must be submitted by using this medication refill link which will be provided. Any prescription refill requests sent via text message, email, Healthie chat, or direct from your pharmacy will not be filled. Due to Federal regulations with controlled substance use, patients are required to fill out a medication wellness check in form to be reviewed by a Med-Fit medical provider once every three months in order to continue prescription use. Upon refill request, patients must update the Patient Assistant Coordinator with current weight. Please note, there is an additional charge from the pharmacy when you pick up your prescription at your pharmacy. The additional charge is determined based on your specific insurance coverage. For coupons visit GoodRx.com Med-Fit, PLLC is not responsible for any other charges or coverage outside of our specific guidelines and protocol. Any other charge is your responsibility. 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. The newer FDA-approved medications available for weight loss have been under a national shortage for some time due to its high demand since entering the market. We understand that it can be a challenge seeking inventory at various pharmacies, and many of our patients have been successful but at times, it does take some pharmacy hunting. It is the patients' responsibility of locating a pharmacy with the prescribed medication in stock as Med-Fit does not have any control over the pharmacy inventory. If you have any questions, please contact your pharmacy directly. I agree to the program terms stated above. By agreeing to terms 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.
Medication Consent I authorize Med-Fit, PLLC to seek and to obtain medical and therapeutic procedures as deemed necessary by duly licensed health care professionals. I freely, knowingly, and willingly choose to participate in the program and assume the associated risks and will take due care during such participation. I hereby release and discharge, indemnify and hold harmless Med-Fit, PLLC its employees, agents, interns, and any other persons or entities acting on its behalf, and the successors and assigns for any and all of the aforementioned persons and entities, against all claims, demands, and causes of action whatsoever, either in law or equity, relating to the diagnosis and/or treatment of any ailment, condition, disease, disability or bodily and psychological injury arising from my participation in the program. I understand that I am solely responsible for any costs arising out of the diagnosis and/or treatment of any ailment, condition, disease, disability, or bodily and psychological injury sustained through my participation in normal or unusual acts associated with Med-Fit. I represent and warrant that I am in good health, and affirm that my participation in Med-Fit, PLLC programs will in no way aggravate any condition(s) present. Should I decide to discontinue use of medication or switch to a different medication, I will notify a Med-Fit, PLLC employee as soon as possible. Med-Fit, PLLC is not responsible for any medication reimbursement.
Women Only I understand that phentermine or any other weight loss medication should not be taken during pregnancy, due to the chance of damage to the fetus. This has been explained to me fully, and I am aware of the risks involved. To the best of my knowledge, I am not pregnant. I am aware of the precautions that should be taken to avoid pregnancy while I am on medication. If I become pregnant, I will advise both the clinic and my OB/GYN immediately.
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 Medical Weight Loss. You further acknowledge that in accepting the terms of this agreement, you agree that you will not request a refund.
Colorado State Protocol: As part of state regulations dispensing medication can only be done on a month-to-month basis. Medication refills are to be requested by the patient 28 days after the last refill. Medication CANNOT be refilled any earlier. Due to Federal regulations with controlled substance use, patients are required to fill out a medication wellness check in form to be reviewed by a Med-Fit medical provider once every three months in order to continue prescription use. Upon refill request, patients must update the Patient Assistant Coordinator with current weight. The newer FDA-approved medications available for weight loss have been under a national shortage for some time due to its high demand since entering the market. We understand that it can be a challenge seeking inventory at various pharmacies, and many of our patients have been successful but at times, it does take some pharmacy hunting. It is the patients' responsibility of locating a pharmacy with the prescribed medication in stock as Med-Fit does not have any control over the pharmacy inventory. If you have any questions, please contact your pharmacy directly.
I agree to the program terms stated above. By agreeing to terms 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.