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