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I hereby authorize Carter J. Moore, MD and the MP Weight Loss Clinic consent for treatment as he deems necessary.
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.
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.
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 :
We will contact you within the next business day to schedule an appointment.
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