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Program Consent

I authorize MrsMD® physician(s),or advanced practice clinician(s) and/or whomever may be designated as the medical assistant(s), to help me in my weight reduction efforts. I understand that my program may consist of a recommended diet, a regular exercise program, instruction in behavioral modification techniques, and may involve the use of medications. Other treatment options may include a personalized diet plan, personalized exercise plan, health coaching, cognitive behavioral therapy for food cravings, or transcranial magnetic stimulation (TMS). I further understand that if medications are prescribed, they may be used for durations exceeding those recommended in the medication package insert. It has been explained to me to my complete satisfaction that these medications have been used safely and successfully in private medical practices as well as in academic centers for periods exceeding those recommended in the medication product literature.

I understand that any medical treatment may involve risks as well as the proposed benefits. I also understand that there are certain health risks associated with remaining overweight or obese. Risks associated with remaining overweight are tendencies to have high and increasing higher blood pressure, diabetes, heart attack and heart disease, arthritis of the joints including hips, knees, feet and back, sleep apnea, and sudden death. I understand that these risks may be modest if I am not significantly overweight but will increase with additional weight gain.

I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances made to me that the program will be successful. I also understand that obesity may be a chronic, life-long condition that may require drastic changes in eating habits and permanent changes in behavior to be treated successfully.

I understand that failing to show up for an appointment I have scheduled, without calling or contacting MrsMD® ahead of time, represents a disruption to operation of the clinic. Failure to show up (“No-Show”) for a pre‐appointed Follow Up Visit, or failure to cancel at least one full business day prior to a scheduled visit will result in the need to pay $119.00 for the missed visit.

I have read and fully understand this consent form and “no show” policy. I have had all of my questions answered to my complete satisfaction. I have been given all the time that I need to carefully read and understand this form.

I acknowledge that I have had an opportunity to review MrsMD’s® HIPPA Policy and also acknowledge that should I request a copy, a copy will be provided to me.

Financial Agreement

I acknowledge and agree to the following terms and conditions regarding the fees for services at MrsMD®:

Fees for services:

1. MrsMD® Membership Fee: $119 per month

2. No-Show/Late Appointment Cancellation Fee: $119 if cancellation is not at least 1 full business day in advance

I acknowledge that if I choose to obtain medication from a compounding pharmacy of my choice or if I choose to have a prescription for the brand Wegovy or Zepbound sent to a retail pharmacy, there will be a recurring monthly fee of $119.00 to cover the cost of one medical evaluation per month and access to the MrsMD® program.

Payment responsibility: I understand that I am responsible for paying fees for services and medications as this agreement outlines. Payment is due at the time of service unless otherwise arranged by the office supervisor. 

No family and friends discounts: I understand that MrsMD® does not offer family and friends discounts. Any special offers or promotions will be posted on the official website or social media platforms of MrsMD®.

Prices Subject to Change: I understand and agree that the prices for services and medications provided by MrsMD® are subject to change at any time without prior notice.

No financial discussions with medical providers: I agree not to discuss pricing or financial matters with medical providers, including doctors, physician assistants, or other practitioners at MrsMD®. I understand that all financial conversations will be directed and handled by office staff.

Acknowledgement to terms: By signing below, I acknowledge that I have read, understood, and agreed to the terms and conditions outlined in this document regarding the fees for service and medications at MrsMD®, including the policy on discounts and promotions and automatic recurring charges. I also acknowledge that this agreement does not encompass all terms of service and that additional terms and conditions may apply.

Medication Consent

Disclaimer: At MrsMD® we are prescribing various medications for weight loss and nutritional supplementation. The compounded formulations of certain medications may be purchased from MrsMD® or you may take a written prescription to a compounding pharmacy of your choice. If you prefer a written prescription, please inform your prescriber. We may prescribe the Brand name of semaglutide (Wegovy) or tirzepatide (Zepbound) for purchase from a retail pharmacy. 

Semaglutide and Tirzepatide

Semaglutide and tirzepatide are injectable prescription medicines used for adults with obesity (BMI ≥30) or who are overweight (excess weight) (BMI ≥27) and have weight-related medical problems to help them lose weight and keep the weight off.

Semaglutide and tirzepatide should be used with a meal plan suggested by your provider and increased physical activity. The injections contain semaglutide or tirzepatide and should not be used with other semaglutide or tirzepatide containing products or other GLP-1 receptor agonist medicines.

It is not known if semaglutide or tirzepatide are safe and effective when taken with other prescription, over-the-counter, or herbal weight loss products. It is not known if semaglutide or tirzepatide can be used safely in people with a history of pancreatitis. It is not known if tirzepatide is safe and effective for use in children under 18 years of age or semaglutide in children under 12 years of age.

Semaglutide and tirzepatide may cause serious side effects, including: Possible thyroid tumors, including cancer. Tell your healthcare provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. In studies with rodents, semaglutide, tirzepatide and medicines that work like them caused thyroid tumors, including thyroid cancer. It is not known if semaglutide or tirzepatide will cause thyroid tumors or a type of thyroid cancer called medullary thyroid carcinoma (MTC) in people.

Do not use Semaglutide or tirzepatide if you or any of your family have ever had a type of thyroid cancer called medullary thyroid carcinoma (MTC) or if you have an endocrine system condition called Multiple Endocrine Neoplasia Syndrome Type 2 (MEN 2).

Do not use semaglutide or tirzepatide if you have had a serious allergic reaction to semaglutide, tirzepatide.

Before using semaglutide or tirzepatide, tell your healthcare provider if you have any other medical conditions, including if you:

• have or have had problems with your pancreas or kidneys.
• have history of diabetic retinopathy.
• have or have had depression, suicidal thoughts, or mental health issues.
• are pregnant or plan to become pregnant. Semaglutide or tirzepatide may harm your unborn baby. You should stop using semaglutide or tirzepatide 2 months before you plan to become pregnant.
• are breastfeeding or plan to breastfeed. It is not known if semaglutide or tirzepatide passes into your breast milk.

Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Semaglutide and tirzepatide may affect the way some medicines work and some medicines may affect the way semaglutide or tirzepatide work. Tell your healthcare provider if you are taking other medicines to treat diabetes, including sulfonylureas or insulin. Semaglutide and tirzepatide slows stomach emptying and can affect medicines that need to pass through the stomach quickly.

What are the possible side effects of semaglutide and tirzepatide?

Semaglutide and tirzepatide may cause serious side effects, including:

• gastroparesis (stomach paralysis).Call your healthcare provider if you have symptoms, including upset stomach or nausea, vomiting, feeling full too soon when eating, belly or abdominal pain or bloating, and heartburn.
• inflammation of your pancreas (pancreatitis). Stop using semaglutide or tirzepatide and call your healthcare provider right away if you have severe pain in your stomach area (abdomen) that will not go away, with or without vomiting. You may feel the pain from your abdomen to your back.
• gallbladder problems. Semaglutide and tirzepatide may cause gallbladder problems, including gallstones. Some gallstones may need surgery. Call your healthcare provider if you have symptoms, such as pain in your upper stomach (abdomen), fever, yellowing of the skin or eyes (jaundice), or clay-colored stools.
• increased risk of low blood sugar (hypoglycemia) in patients with type 2 diabetes, especially those who also take medicines for type 2 diabetes such as sulfonylureas or insulin. This can be both a serious and common side effect. Talk to your healthcare provider about how to recognize and treat low blood sugar and check your blood sugar before you start and while you take semaglutide or tirzepatide. Signs and symptoms of low blood sugar may include dizziness or light-headedness, blurred vision, anxiety, irritability or mood changes, sweating, slurred speech, hunger, confusion or drowsiness, shakiness, weakness, headache, fast heartbeat, or feeling jittery.
• kidney problems (kidney failure). In people who have kidney problems, diarrhea, nausea, and vomiting may cause a loss of fluids (dehydration) which may cause kidney problems to get worse. It is important for you to drink fluids to help reduce your chance of dehydration.
• serious allergic reactions. Stop using semaglutide and tirzepatide and get medical help right away, if you have any symptoms of a serious allergic reaction, including swelling of your face, lips, tongue, or throat; problems breathing or swallowing; severe rash or itching; fainting or feeling dizzy; or very rapid heartbeat.
• change in vision in patients with type 2 diabetes. Tell your healthcare provider if you have changes in vision during treatment with semaglutide or tirzepatide.
• increased heart rate. Semaglutide and tirzepatide can increase your heart rate while you are at rest. Tell your healthcare provider if you feel your heart racing or pounding in your chest and it lasts for several minutes.
• depression or thoughts of suicide. You should pay attention to any mental changes, especially sudden changes in your mood, behaviors, thoughts, or feelings. Call your healthcare provider right away if you have any mental changes that are new, worse or worry you.

The most common side effects of semaglutide and tirzepatide may include nausea, diarrhea, vomiting, constipation, stomach (abdomen) pain, headache, tiredness (fatigue), upset stomach, dizziness, feeling bloated, belching, gas, stomach flu and heartburn.

Do not share your semaglutide or tirzepatide injections with other people, even if the needle has been changed. You may give other people a serious infection or get a serious infection from them.

I understand that certain herbal products, vitamins, minerals, nutritional supplements, prescription and non-prescription medications may result in side effects when they interact with semaglutide or tirzepatide.

I HAVE READ AND FULLY UNDERSTAND THIS CONSENT FORM AND I REALIZE I SHOULD NOT SIGN THIS FORM IF ALL ITEMS HAVE NOT BEEN SATISFACTORY EXPLAINED TO ME. WITH MY SIGNATURE, I ACKNOWLEDGE THAT MY QUESTIONS HAVE BEEN ANSWERED FULLY, AND THAT I HAVE BEEN REQUESTED TO READ THIS FORM AND HAVE BEEN GIVEN AMPLE TIME TO UNDERSTAND ALL ITS CONTENTS.

Telemedicine Consent

Introduction

Telemedicine allows patients to access care using audio-video interface such as videoconferencing.

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:

• Improved access to care by enabling a patient to remain in his/her home or office.
• More efficient medical evaluation and management.
• Obtaining expertise of a distant specialist.

Possible Risks:

As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgmental errors;

By signing this form, I understand the following:

1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand that I have the right to inspect all information obtained in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
4. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time.
5. I understand that it is my duty to inform my provider of any other healthcare providers involved in my medical/psychiatric care.
6. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

Patient Consent to the Use of Telemedicine

I have read and understand the information provided above regarding telemedicine, have discussed it with my provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.

I hereby authorize MrsMD® to use telemedicine in the course of my diagnosis and treatment.