Patient Informed Consent Form
Patient Name:______
Date of Birth: ______
Medical Record Number: ______
- I declare thatI am over 16 years of age, I am not pregnant or lactating, I do not havecongestive heart failure or current cancer markers, andI do not have a history ofovarian hyper stimulation syndrome (OHSS) or cancer during the past two years.
- Ihereby agree to undertake the HCG Diet program for weight loss recommended by
______
[INSERT practitioner name and practice]
- I understand that the consultant is not a medical doctor and that he/she is not acting as such.
[DELETE if not applicable]
- I have been informed of:
• how the HCG Diet workscompared to how other diets work
• weight loss required to achieve a body mass index (BMI) within the ‘normal’ weight range for my ethnicity
• possible risks and benefitsduring Phase 1 Weight Loss of the HCG Diet program including headache, and if pre-disposed, gout, gallstones, enlargement and rupture of ovarian cysts, increased libido and erectile function [males] and increased fertility [females reproductive age]
• likelihood of achieving my weight goal
• probable consequence of declining the recommended or alternative therapies
• correct preparation, usage and storage of HCG
• need to seek immediate medical attention if I experience a change in health or have a medical emergency of any kind
• frequency of follow up appointments to monitor my progress
- I have divulged all relevant medical historythat could affect my suitability as a candidate for the HCG Diet program and understand that I may need to temporarily discontinue use of ______
[INSERT treatments, medications and supplements] (If none, leave blank)
during Phase 1 Weight Loss of the HCG Diet
and that I may need to temporarily discontinue use of ______
[INSERT treatments, medications and supplements] (If none, leave blank)
during Phase 2 Stabilization of the HCG Diet.
- I consent to measurements and photographs being taken and stored on my medical records.
- I acknowledge that even though many people report extraordinary results, HCG has not specifically been approved by the Food and Drug Administration (FDA)for weight loss and that I have received no guarantee regarding the outcome of my course of treatment.
- I understand that if I am not satisfied with the result or I do not complete the program for any reason,fees paid for any products or services are non-refundable.
______
Patient Signature Patient Name (PLEASE PRINT) Date