Patient Responsibility Statement/Agreement
I agree to the following:
- I will contact my local emergency room or dial 911 if any adverse or allergic reaction occurs so that I will receive treatment immediately.
- If I am taking medications for high blood pressure, I agree to measure my blood pressure at least daily or more frequently if so directed by the LDE physician. I will notify my personal physician if my blood pressure increases or decreases by more than 10 points.
- If I am taking medication for diabetes, I agree to monitor my blood glucose at least daily or more frequently if so directed by the LDE physician. If my blood sugar falls below 70 or I experience symptoms of low blood sugar, I will notify my personal physician in a timely manner to adjust my medication appropriately.
- Last Diet Ever Medical Weight Loss Clinic, is not responsible for any falsified medical information, and will not be held liable. Further treatment may be discontinued without refund.
- I agree to the Last Diet Ever Clinic privacy policies, and understand my medical information is confidential for clinic use only. Last Diet Ever may contact my family physician if necessary for continued care. All Last Diet Ever employees maintain strict confidentiality, and all employees adhere to HIPAA regulations.
- I agree to immediately notify Last Diet Ever of any new medical conditions that arise during the course of my weight loss program.
- I agree to report my weight loss via phone/e-mail every week to the Last Diet Ever office.
- I agree to keep all scheduled follow up appointments as applicable to the program. I understand that Last Diet Ever reserves the right to discontinue treatment if I fail to comply with the program requirements.
hCG Program
Requirements for the program:
- Must follow the diet EXACTLY as advised (with absolutely no cheating!);
- Must drink enough water;
- Has no underlying medical problems that would interfere with weight loss (sleep apnea, undertreated hypothyroidism, certain food allergies);
- Is not taking medications that may interfere;
- Not doing excessively high levels of exercise;
You are also required to report your weight loss weekly or Last Diet Ever reserves the right to discontinue treatment.
B12 Program (Optional)
B12 injections are recommended and should be received at regular 1 week intervals.
Supplements (Optional)
- I have been informed of the supplements available and understand their benefits.
Refunds: Once you have met with our medical advisor, paid for your weight loss program, and the prescription hCG has been ordered from the pharmacy, there can be no refund, partial or otherwise. Once prescription medication is dispensed, legally there can be no return. All sales are final.
Cancellations: Should you find for some unforeseen circumstance you wish to cancel your program and have met with our Medical Advisor, but the prescription has NOT been ordered, a partial refund of money can be issued (the total program cost minus $75).
Refunds and cancellations will be processed within 30 days of notification.
Any and all disputes must be filed in the Medina County Court System, Medina, Ohio.
Patient Agreement
I have chosen to participate in a Last Diet Ever Medical Weight Loss Clinic program. I am aware that results may vary and are not guaranteed.
With prescription hCG, there are risks of possible side effects occurring such as fatigue, mild headaches, bruising or swelling at the injection site or allergic reaction, etc.
With prescription vitamin injections (B12) there are risks of possible side effects occurring such as an allergic reaction or sensitivity to any ingredients.
I agree that I have been counseled on a specific weight loss program for me with diet and nutritional supplementation, B12 injections, and prescription hCG injections to attain my targeted weight loss. I must follow the program to achieve the desired results. I have been counseled on self-injection (if applicable) and assume full responsibility for myself. If applicable, I will also dispose of used syringes properly. Patients who are found to have submitted fraudulent information will be terminated from the program. Any medication is strictly for the use of the patient and is not to be transferred or distributed, modified or used by any other party. The use of prescription hCG for weight loss has not been specifically approved by the FDA. I understand that the use of prescription hCG for weight loss is an off-label usage by a physician and I have read and understand all disclosures provided by Last Diet Ever Medical Weight Loss Clinic.
Participation Waiver: Last Diet Ever Medical Weight Loss Clinic and its staff, clinicians, and/or physicians are not responsible for treatment of any medical condition disclosed by any abnormal lab reports or myself. I agree to seek medical treatment for any identified medical problems with my primary care provider of choice. In all the disclosed risks, I will hold harmless: the physicians, nurses and all personnel of Last Diet Ever Medical Weight Loss Clinic for any adverse reactions or occurrences that my occur while participating in this program.
R E A L L Y !
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