Download patient informed consent for appetite suppressants

WhyWeight,LLC
7325S.PierceSt,Suite102
Littleton,CO80128
PATIENTINFORMEDCONSENTFORAPPETITESUPPRESSANTS
I.
PROCEDUREANDALTERNATIVES
1. I, _____________________________________, (patient or legal guardian) authorize D.S. Salter, M.D. and
WhyWeight,LLCtoassistmeinmyweightreductionefforts.Iunderstandmytreatmentmyinvolve,butis
notlimitedto,theuseofappetitesuppressantsformorethan12weeksandwhenindicatedinhigherdoses
thantherecommendeddosesonthelabels.
2. Ihavereadandunderstandthefollowingstatementsmadebymydoctor:
“Medications,includingtheappetitesuppressants,havelabelingworkedoutbetweenthemakerof
the medication and the Food and Drug Administration. This labeling contains, among other things,
suggestions for using the medication. The appetite suppressant labeling suggestions are generally
basedonshorter-termstudies(upto12weeks)usingthedosagesindicatedinthelabeling.
“Asaphysician,Ihavefoundtheappetitesuppressantshelpfulforperiodfarinexcessof12weeks
andattimesinlargerdosesthanthosesuggestedinthelabeling.Asaphysician,Iamnotrequiredto
usethemedicationasthelabelingsuggests,butIdousethelabelingasasourceofinformationalong
with my own experience, the experience of my colleagues, recent longer-term studies and
recommendationsofuniversitybasedinvestigators.Baseonthese,Ihavechosen,whenindicated,to
useappetitesuppressantsforlongerperiodsoftimeand,attimes,inincreaseddoses.
“Suchusagehasnotbeensystematicallystudiedasthatsuggestedinthelabelinganditispossible,
aswithmostothermedications,thattherecouldbeserioussideeffects.(AsnotedinIIbelow).
“Asabariatricphysician,Ibelievetheprobabilityofsuchsideeffectsisoutweighedbythebenefitof
theappetitesuppressantuseforlongerperiodsoftime,andwhenindicated,intheincreaseddoses.
However,youmustdecideifyouarewillingtoaccepttheriskofsideeffects,eveniftheymightbe
serious,forthepossiblehelptheappetitesuppressantsusedinthismannermaygive.”
3. I understand that it is my responsibility to follow the instructions carefully and to report to the doctor
treating me for my weight, any significant medical problem(s) that I think may be related to my weight
controlprogramassoonasreasonablypossible.
4. Iunderstandthepurposeofthistreatmentistoassistmeinmydesiretodecreasemybodyweightandto
maintainthisweightloss.Iunderstandmycontinuingtoreceivetheappetitesuppressantswillbedependent
onmyprogressinweightreductionandweightmaintenance.
5. Iunderstandthereareotherwaysandprogramsthatcanassistmeinmydesiretodecreasemybodyweight
andtomaintainthisloss.Inparticular,abalancedcalorie-countingprogramoranexchange-eatingprogram
without the use of appetite suppressants would likely prove successful if followed even though I would
probablybehungrierwithouttheappetitesuppressants.
PatientInformedConsentforAppetiteSuppressants
8/2016
WhyWeight,LLC
7325S.PierceSt,Suite102
Littleton,CO80128
II. RISKSOFPROPOSEDTREATMENT
1. I understand this authorization is given with the knowledge that the use of the appetite suppressants for
more than 12 weeks and in higher doses than the dose indicated on the labeling involves some increased
risks and hazards. The more common risks include: nervousness, sleeplessness, headaches, dry mouth,
weakness,tiredness,psychologicalproblems,medicationallergies,highbloodpressure,rapidheartbeat,and
heartirregularities.Theseandotherpossibleriskscould,onoccasion,beseriousorfatal.
III. RISKSASSOCIATEDWITHBEINGOVERWEIGHTOROBESE
1. Iamawarethattherearecertainrisksassociatedwithremainingoverweightorobese.Amongthemarethe
tendenciestowardshighbloodpressure,diabetes,heartattackandheartdisease,andarthritisofthejoints
toincludehips,kneesandfeet.IunderstandtheserisksmaybemodestifIamslightlyoverweight,butthat
theseriskscanincreasesignificantlyasmyweightincreases.
IV. NOGUARANTEES
1. I understand that much of the success of the program will depend on my efforts and that there are no
guaranteesorassurancesthattheprogramwillbesuccessful.IalsounderstandthatIwillhavetocontinue
watchingmyweightfortheremainderofmylifetimeinordertobesuccessful.
V. PATIENT’SCONSENT
1. IhavereadandfullyunderstandthisconsentformandIrealizeIshouldnotsignthisformifallitemshave
notbeenexplainedoranyquestionswerenotansweredtomycompletesatisfaction.Ihavebeenurgedto
takeallthetimeIneedinreadingandunderstandingthisformandintalkingwithmydoctorregardingrisks
associatedwiththeproposedtreatmentandregardingothertreatmentnotinvolvingappetitesuppressants.
NOTICETOALLPATIENTS.
IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THE PROPOSED TREATEMENT, OR ANY
QUESTIONSWHATSOEVERCONCERNINGOTHERPOSSIBLETREATMENTS, ASK DR. SALTER PRIORTOSIGNING
THISCONSENTFORM.
*****DONOTSIGNTHISINFORMEDCONSENTUNTILYOUHAVESPOKENWITHDR.SALTER.*****
Patient’sSignature:___________________________________________Date:_______________________________
PHYSICIAN’SDECLARATION
I have encouraged the patient to ask any questions she/he may have regarding eh content of this form and have
answered all questions. To the best of my knowledge, I feel the patient is informed adequately concerning the
benefitsandrisksassociatedwiththeuseofappetitesuppressants,thebenefitsandrisksassociatedwithalternative
therapies,andtherisksofcontinuinginanoverweightstate.Afteradequateinformation,thepatienthasconsented
totherapyinvolvingappetitesuppressantsinthemannerindicatedabove.
Physician’sSignature:____________________________Date:_________________COLic.#:___________________
PatientInformedConsentforAppetiteSuppressants
8/2016