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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