Terms and conditions
I declare that I have been informed by Déjà Vu Med Spa of the cost of the treatment, the treatment modalities, the side effects, the possible alternative treatments, the possible risks and complications that may result from this treatment and in doing so I hereby and forever discharge Déjà Vu Med Spa, its officers and employees from all claims, demands, actions and cause of action arising out of the performance of this treatment. I have reviewed my medical history, medications, recent illnesses, recurring illnesses or any prior surgeries with the staff. I have obtained lab testing (from Déjà Vu or my PCP) or written permission from my PCP prior to starting the weight loss program. I have had all of my concerns and questions answered prior to starting treatment. I have reviewed this document in its entirety and agree to the terms of my contract. I agree to have weekly blood pressure monitoring and BMI/weight monitoring. I may not be able to start the medication or may be taken off the medication due to elevated blood pressure (140/80 or higher). I will not be prescribed the medication or may be taken off if I have a normal BMI (<25).
Drug Labeling
• All prescription medications, including appetite suppressants, have labeling approved by the FDA. This labeling contains suggestions of the use of the medication. The labeling found on most appetite suppressants is based upon studies of less than 12 weeks using the dosage indicated on the labels.
• Notwithstanding such labeling, I understand that my physician, based upon his experience, the experience of his colleagues, and other factors, may recommend the use of such medications for a period of time or at doses in excess of those recommended by the manufacturer’s label. I further understand that such usage may not have been systemically studied as that suggested by the labeling, and it is possible, as with many other medications, that serious side effects could occur.
• After consulting my physician, I believe that the probability of such side effects is outweighed by the potential benefit of the appetite suppressants being prescribed and/or provided to me, notwithstanding the fact that the dosage and/or term may exceed those recommended by the manufacturer.
Instructions
• I understand that it is my responsibility to follow my physician’s instructions carefully and to report any medical problems immediately, regardless of whether I think that it may be related to my weight control program.
• I am not pregnant now and I will report if I become pregnant to my physician immediately.
• I understand any treatments rendered are solely for the purpose of weight control. The diagnosis and treatment of other illnesses or diseases is not the responsibility of Déjà Vu Med Spa. If I become ill, I will seek treatment on my own and I will discontinue the use of diet medication until it is determined safe to resume the weight control program.
Diet and Exercise
• I understand that there are other ways and programs that can assist me in my desire to decrease my body weight and to maintain any weight loss. In particular, a balanced diet
combined with physical exercise is recommended, with or without the use of appetite
suppressants. I understand that a program including a revised diet and physical exercise
could prove successful without appetite suppressants if I followed it, even though I would
probably be hungrier than if I used appetite suppressants.
Risk of Treatment
• I understand that this authorization is given to me with the knowledge that the use of appetite suppressants poses various health risks, including but not limited to, pulmonary hypertension, nervousness, sleeplessness, headaches, dry mouth, weakness, fatigue, psychological problems, medical allergies, high blood pressure, rapid heartbeat, and heart irregularities. These and other possible risks could occasionally be serious or even fatal.
Risk of Obesity
• I understand that remaining overweight or obese poses certain risks. They are high blood pressure, diabetes, heart disease, heart attack, arthritis, chronic pain and cancer. I understand that these risks may be modest if I am not very overweight, but these risks increase significantly with any weight gain.
No Guarantees
• I understand that much of the success of this program will depend on my efforts. I understand that there are no guarantees or assurances that the program will be successful. I also understand that I will have to continue watching my weight all of my life to be successful.
• Most insurance companies do not provide coverage for weight loss programs. All services must be paid for in full at the time services are rendered. We accept cash, debit, or charge.
• I will not sell or share my medications with anyone.
• I may have a family member pick up my medications, only if I provide written consent prior.
• I will only be allowed 3 months of prescription weight loss medication and then am required to take a break for a minimum of two months.
• I can always meet with a weight loss specialist and may be charged and additional fee for the visit.
• I will not visit another office for the purpose of obtaining additional or duplicate medications of the same type.
• Once I am signed up for a specific plan
o I may upgrade to a higher tiered plan at any time.
o I may cancel at any time.
o Services are nonrefundable. You may move unused credit for other services or products.
Lab Studies
I will provide labs that are less than 6 months old (new labs must be obtained before any refills if greater than 6 months old) for review. The labs are reviewed for the purpose of the weight loss program only. They are not to diagnose and treat medical conditions. They are not a substitute for seeking medical attention. It is my responsibility to seek medical care with my PCP. Copies of lab studies will be provided upon request. Lab fees are my responsibility and I will not be reimbursed if I am unable to participate in the weight loss program.