I agree to the Consent: I understand the program involves the daily self-administered injection of HCG or any other form of the hormone HCG (Human Chorionic Gonadotropin) with a minimum intake of 500 calories per day, modifying if necessary, as discussed and decided upon. I acknowledge that even though many people report extraordinary results, HCG has not specifically been approved by the Food and Drug Administration (FDA) for weight loss and that I have received no guarantee regarding the outcome of my course of treatment.
I understand that if I am not satisfied with the result or I do not complete the program for any reason, fees paid for any products or services are non-refundable.
I understand that HCG has been historically used and is commonly prescribed for weight loss by physicians, but HCG used for weight loss is an “off label” use and is not FDA- approved. I am aware that although the use of HCG is generally free of negative side effects, there is the possibility of the following: headache, fatigue, constipation, bruising at injection site, and temporary variation in menstrual cycle.
(1) The Weight-Loss Consumer Bill of Rights shall consist of the following provisions:
- (A) WARNING: RAPID WEIGHT LOSS MAY CAUSE SERIOUS HEALTH PROBLEMS. RAPID WEIGHT LOSS IS WEIGHT LOSS OF MORE THAN 1 1⁄2 TO 2 POUNDS PER WEEK OR WEIGHT LOSS OF MORE THAN 1% OF BODY WEIGHT PER WEEK AFTER THE SECOND WEEK OF PARTICIPATION IN A WEIGHT LOSS PROGRAM.
- (B) CONSULT YOUR PERSONAL PHYSICIAN BEFORE STARTING ANY WEIGHT-LOSS PROGRAM.
- (C) ONLY PERMANENT LIFESTYLE CHANGES, SUCH AS MAKING HEALTHFUL FOOD CHOICES AND INCREASING PHYSICAL ACTIVITY, PROMOTE LONG-TERM WEIGHT LOSS.
- (D) QUALIFICATIONS OF THIS PROVIDER ARE AVAILABLE UPON REQUEST.
- (E) YOU HAVE A RIGHT TO:
- (1) ASK QUESTIONS ABOUT THE POTENTIAL HEALTH RISKS OF THIS PROGRAM AND ITS NUTRITIONAL CONTENT, PSYCHOLOGICAL SUPPORT AND EDUCATIONAL COMPONENTS.
- (2) RECEIVE AN ITEMIZED STATEMENT OF THE ACTUAL OR ESTIMATED PRICE OF THE WEIGHT LOSS PROGRAM, INCLUDING EXTRA PRODUCTS, SERVICES, SUPPLEMENTS, EXAMINATIONS, AND LABORATORY TESTS.
- (3) KNOW THE ACTUAL OR ESTIMATED DURATION OF THE PROGRAM.
- (4) KNOW THE NAME, ADDRESS, AND QUALIFICATIONS OF THE PHYSICIAN, DIETICIAN OR NUTRITIONIST WHO HAS REVIEWED AND APPROVED THE WEIGHT- LOSS PROGRAM ACCORDING TO 468.505(1)(I), FLORIDA STATUTES.