AUTHORIZATION OF TREATMENT AND ASSIGNMENT OF BENEFITS
I hereby authorize Carter J. Moore, MD and the MP Weight Loss Clinic consent for treatment as he deems necessary.
COLLECTION POLICY
I understand that all charges incurred become my responsibility. I understand that any applicable amounts are due on the
same day services are rendered. *We accept Visa, MasterCard, and Discover cards.
NOTICE OF PRIVACY PRACTICE PATIENT ACKNOWLEDGEMENT
I have received and/or reviewed this practice's Notice of Privacy Practices. The notices provides 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.
Informed Consent for Treatment:
The patient was given the option of a calorie restrictive diet, phentermine, tirzepatide, or semaglutide.
If phentermine was chosen, I understand that it will lose its effect over time and to maintain my new weight, I will need to restrict my calorie intake.
If semaglutide or tirzepatide is chosen, I agree to the following :
- I do not have a history of MEN2 or Medullary Thyroid Cancer.
- I understand that although rare, gallbladder disease, pancreatitis, or paralyzed intestines 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 will come in approximately every three (3) months for a follow-up appointment.
- 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 stop the medications if I decide to, or if I become pregnant.
