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PHARMXHEALTHONE
MEDICAL WEIGHT LOSS CONSENT & ACKNOWLEDGMENT

Nationwide Telehealth + Local In-Clinic Services

This Medical Weight Loss Consent & Acknowledgment outlines the potential benefits, risks, responsibilities, and limitations associated with participating in a medically supervised weight loss program through PharmXHealthOne. By signing below, I confirm that I have read, understood, and voluntarily agree to the following:

 

1. Purpose of the Program

I understand that the PharmXHealthOne Medical Weight Loss Program is designed to support weight reduction and metabolic health through a combination of:

  • Prescription medications (including Semaglutide, Tirzepatide, or others when medically indicated)

  • Nutrition guidance

  • Lifestyle recommendations

  • Medical monitoring

  • Optional peptide or hormone therapies (if appropriate)

 

I understand that participation does not guarantee weight loss or any specific results.

 

2. Telehealth Services & Scope of Practice

I acknowledge that:

  • My evaluation may be conducted through telehealth or in-person, depending on my location and clinical needs.

  • Telehealth services follow state-specific medical regulations, which may limit what medications can be prescribed in some states.

  • A prescription will only be issued if the provider determines it is safe and medically appropriate.

3. Medication Disclosure (Semaglutide, Tirzepatide, and Others)

I acknowledge that:

  • Some medications may be FDA-approved for weight loss or diabetes, while compounded formulations may not be FDA-approved.

  • Compounded medications are produced by licensed 503A or 503B compounding pharmacies and may differ from branded products.

  • The provider will determine whether an FDA-approved or compounded medication is appropriate based on availability, clinical need, and state law.

 

I understand I will be informed when a prescription is compounded.

 

4. Risks, Side Effects & Contraindications

I understand that weight loss medications may cause side effects, including but not limited to:

Common:

  • Nausea, vomiting, constipation, diarrhea

  • Appetite suppression

  • Abdominal discomfort

  • Headache or fatigue

 

Serious (but less common):

  • Pancreatitis

  • Gallbladder disease

  • Kidney complications

  • Hypoglycemia

  • Allergic reactions

  • Potential thyroid risks (rodent studies; relevance to humans unknown)

 

I agree to notify PharmXHealthOne immediately if serious or unexpected symptoms occur.

 

I affirm that I have disclosed:

  • My complete medical history

  • All medications and supplements

  • Any personal or family history of thyroid cancer, MEN2, or pancreatitis

 

5. Laboratory Testing & Monitoring

I acknowledge the following:

  • Baseline and follow-up laboratory tests may be required.

  • I am responsible for completing labs within the timeframe requested by the provider.

  • Failure to complete required tests may result in treatment delay, suspension, or discontinuation for my safety.

 

6. Pregnancy, Breastfeeding & Fertility

I understand that:

  • Weight loss medications are NOT recommended during pregnancy or breastfeeding.

  • If I become pregnant or suspect pregnancy, I must discontinue medication immediately and notify my provider.

 

7. Contraindications & Provider Discretion

I understand that PharmXHealthOne may decline to prescribe or continue treatment if:

  • I have contraindications

  • I fail to provide accurate medical information

  • I do not comply with required monitoring

  • My health status changes

  • State or federal regulations restrict prescribing

Completion of a consultation does not guarantee medication approval.

 

8. Lifestyle Responsibilities

I understand that weight loss medication is most effective when combined with:

  • A healthy nutrition plan

  • Regular physical activity

  • Hydration and sleep optimization

  • Stress management

Medication does not replace my responsibility for lifestyle changes.

 

9. No Guarantee of Results

I acknowledge that:

  • Individual results vary significantly.

  • Weight loss outcomes depend on numerous factors including adherence, metabolism, medical conditions, and lifestyle.

  • PharmXHealthOne does not guarantee any specific weight loss amount, timeframe, or outcome.

 

10. State-Specific Telehealth & Medication Regulations

I understand that state laws may limit or prohibit:

  • Prescribing compounded medications

  • Prescribing certain medications via telehealth

  • Issuing prescriptions without in-state labs or physical examination

If my state restricts a medication, PharmXHealthOne may not be able to provide it.

 

11. Local vs. Nationwide Treatment Availability

I understand:

  • Weight loss medications and telehealth oversight are available nationwide.

  • IV treatments and equipment-based procedures are available only in Florida (Boynton Beach) or within a 20-mile mobile radius.

 

12. Financial Responsibility

I acknowledge that:

  • Medications and weight loss services may NOT be covered by insurance.

  • I am fully responsible for program fees, medication costs, labs, and follow-up appointments.

  • Payments for compounded medications are non-refundable once processed by the pharmacy.

 

13. Compliance & Communication

I agree to:

  • Take medications exactly as prescribed

  • Attend follow-up visits

  • Report side effects promptly

  • Avoid sharing my medication with others

 

14. Informed Consent

By signing this form:

  • I confirm I have read and understand all information provided.

  • I have had the opportunity to ask questions and they were answered to my satisfaction.

  • I voluntarily agree to participate in the PharmXHealthOne Medical Weight Loss Program.

  • I understand I may withdraw from treatment at any time, but fees already paid may not be refundable.

 

Patient Acknowledgment

Patient Full Name: _______________________________

Date of Birth: _______________________________

State of Residence: _______________________________

Signature: _______________________________________

Date: _______________________________

Provider Name: ___________________________________

Provider Signature: _________________________________

Date: _______________________________

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