AUTHORIZATION OF TREATMENT AND ASSIGNMENT OF BENEFITS

I hereby authorize Carter J. Moore, MD, and the MP Weight Loss Staff to consent for treatment as he deems necessary.

NOTICE OF PRIVACY PRACTICE PATIENT ACKNOWLEDGEMENT

I have received and/or reviewed this practice's Notice of Privacy Practices. The notices provide details about uses and disclosures of my protected health information that may be needed by this practice, my individual rights, how I may exercise these rights, and the practice's legal duties with respect to my information. I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all protected health information resident at, or controlled by, the practice. I understand that I may obtain this practice's current Notice of Privacy Practices upon request.

COLLECTION POLICY

I understand that all charges incurred become my responsibility. Though an insurance claim may be filed, as a convenience to me, I understand that any applicable co-pays, deductibles, or co-insurance amounts are due on the same day services are rendered. *We accept all major credit and debit cards. (Insurance will only be billed for any lab work.)

I do not have a history of MEN2 or Medullary Thyroid Cancer.

I understand that although rare, gallbladder disease or pancreatitis may occur. I should report to the office or other health care professionals if I experience any abdominal pain.

Weight loss is likely, but not guaranteed.

If nausea or vomiting occurs, I should report this to the office.

I should inform my PCP that I am using this medication.

I understand follow up appointments are required to maintain a proper dosing schedule.

If surgery is planned, I will stop these medications two weeks prior to surgery.

I understand that Tirzepatide and Semaglutide can decrease the absorption of oral birth control pills and may decrease their effectiveness. Other alternatives are available.

I will discontinue the medications if I choose to or if I become pregnant.

I certify that I am the parent or legal guardian of the minor patient listed on this form and that I have legal authority to consent to medical care on behalf of this minor.
• I authorize MP Weight Loss and its licensed medical providers and staff to evaluate, examine, and provide medically appropriate care to the minor patient. This may include medical history review, vital signs, weight and BMI assessment, lab review or lab orders, health counseling, treatment planning, medication discussion, follow-up recommendations, and other care deemed medically appropriate by the provider.
• I understand that all treatment decisions, including any weight-loss medication recommendations or prescriptions, are subject to provider review, medical eligibility, clinic policy, and applicable law.
• I understand that MP Weight Loss may require direct parent/legal guardian approval for new treatment decisions, prescription changes, medication starts, procedures, or any care the provider determines requires additional consent.
• I understand that I may revoke this authorization in writing at any time, except to the extent that MP Weight Loss has already relied on it.