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Releana Informed Consent

By Tammy Williams,2014-06-28 10:28
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Releana Informed Consent ...

    Releana? Informed Consent

    Releana? is a prescription medication used by Millennium Medical SPA, LLC in its weight loss program.

Conditions of Participation

You will have a consultation before starting Releana? in combination with a VLCD (very

    low calorie diet). You will undergo a fasting blood test. A comprehensive metabolic

    panel to measure kidney function, liver function, hemoglobin, hematocrit, glucose, lipids

    and thyroid function. A blood pregnancy test will also be performed.

    You will be weighed, your blood pressure and pulse will be recorded, and your

    measurements will be recorded using pre-set measuring points.

    We will take photos of you when you start the program as well as when you either finish

    or reach your goal weight. These photos will be kept in your chart and confidential

    unless specified that we may publish them for advertising purposes.

    We will photocopy your driver’s license and it will be kept in your chart for physical

    identification.

    If at any time during your office visit, you should have any questions, concerns, or

    problems, you are encouraged to consult with our staff. If you should experience any

    problems or concerns after being discharged from our office, please call

    949 863-1667with any questions.

    Release of Information

On certain instances, we can release your medication to a friend/family member or mail

    your medication to your home. Please read the following statements and initial if you

    would like us to release information and/or medicine.

______ Millennium Medical Spa may leave private information on your answering

    machine. For example, blood work results, confirmations, appointment time, etc.

______ Millennium Medical Spa may (when appropriate) ship your medication to your

    home.

______ Millennium Medical Spa may (when appropriate) release your medication to a

    friend/family member.

Risks

Releana? is virtually free of negative side effects, but because you must follow a very low

    calorie, low fat diet that can sometimes trigger a gallbladder attack in individuals who are

    genetically pre-disposed to gallbladder disease.

    With any drug there is the possibility of an allergic reaction or unusual reaction that

    may cause skin rash, difficulty breathing, collapse, or even death.

    Your medication will be discontinued if there is a severe adverse reaction.

Notice of Privacy Practices

In accordance with HIPAA federal regulations, Millennium Medical Spa will not disclose any

    information about you or your personal health without your permission. All information

    received while a patient (and if/when you decline to be a patient any longer) at Millennium

    Medical Spa will be kept confidential.

    In certain cases, it may be necessary for Millennium Medical Spa to release confidential

    documents. Your Private health information may be disclosed or used for treatment,

    payment, or necessary health care operations. By signing this agreement, you are

    consenting to allow Millennium Medical Spa to do so in necessary, rare occasions.

I understand that the program and medications may involve risk. I understand that there

    are no refunds, returns or store credit for medication and that there is no weight loss

    guarantee with our program. I have read and understand the information given to me about

    the medications. I have asked and had answered any questions that I may have after

    reading this form. I understand the possible side-effects and agree to advise Millennium

    Medical SPA, LLC should they occur. I understand that I may quit the program at any time. I

    agree to stop the Releana? if I become pregnant and agree to advise Millennium Medical

    SPA, LLC should I decide to become pregnant. No adverse side effects or complications are

    expected, but in the event that an illness does occur, I understand that I need to contact

    Millennium Medical SPA, LLC. If I experience an emergency situation, I understand that I

    need to go to an emergency facility.

YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THE INFORMATION

    ABOVE, HAVE HAD YOUR QUESTIONS ANSWERED, HAVE HAD POTENTIAL SIDE

    EFFECTS EXPLAINED, AND AGREE TO NOTIFY MILLENNIUM MEDICAL SPA, LLC OF ANY

    CHANGE IN YOUR HEALTH STATUS.

________________________________________

    Client’s Name (PLEASE PRINT) Client’s Signature Date

____________ ____________________

    Witness Sarah/OfficeForms/ReleanaConsent 8/15/07

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