PATIENT ACKNOWLEDGMENT, INFORMED CONSENT, ASSUMPTION OF RISK, AND RELEASE OF LIABILITY
IMPORTANT DISCLOSURE
I understand that Sands Weight Loss & Wellness (“Sands”) is not a medical practice and does not provide medical diagnosis, treatment, medical advice, or prescriptions.
I acknowledge and agree that:
- All medications, peptides, hormone therapies, GLP-1 medications, GLP-1/GIP medications, and other treatments are prescribed solely by a licensed healthcare provider.
- The prescribing healthcare provider is solely responsible for evaluating my medical history, determining my eligibility for treatment, prescribing medications, monitoring my care, and providing medical advice.
- Sands acts solely as a facilitator, educator, administrative coordinator, and support service.
- Sands employees, representatives, coaches, consultants, and staff are not acting as my physician and are not providing medical advice.
- Any medical questions, concerns, side effects, adverse reactions, dosage changes, or treatment decisions must be directed to my prescribing healthcare provider.
COMPOUNDED MEDICATION DISCLOSURE
I understand that certain medications and peptides offered through the prescribing provider may be compounded medications.
I acknowledge that compounded medications:
- Have not been reviewed or approved by the U.S. Food and Drug Administration (FDA) for safety, effectiveness, or quality.
- Are prepared by licensed compounding pharmacies pursuant to a prescription from a licensed healthcare provider.
- May differ from commercially available FDA-approved medications.
- Have not undergone the same FDA approval process as commercially manufactured drugs.
RISKS AND POTENTIAL SIDE EFFECTS
I understand that all medications and peptides carry known and unknown risks.
Potential risks associated with GLP-1 medications, GLP-1/GIP medications, hormone therapies, peptides, and related treatments may include, but are not limited to:
Gastrointestinal Risks
- Nausea
- Vomiting
- Diarrhea
- Constipation
- Abdominal pain
- Bloating
- Acid reflux
- Indigestion
- Delayed gastric emptying (gastroparesis)
- Dehydration
Metabolic Risks
- Low blood sugar (hypoglycemia)
- Dizziness
- Weakness
- Fatigue
- Loss of appetite
- Nutritional deficiencies
Pancreatic and Gallbladder Risks
- Pancreatitis
- Gallstones
- Gallbladder disease
- Gallbladder inflammation
Endocrine and Thyroid Risks
- Thyroid nodules
- Thyroid tumors
- Medullary thyroid carcinoma (MTC)
- Endocrine abnormalities
Vision and Neurological Risks
- Blurred vision
- Worsening diabetic retinopathy
- Vision changes
- Loss of vision
- Headaches
- Dizziness
Cardiovascular Risks
- Increased heart rate
- Palpitations
- Blood pressure changes
Psychiatric Risks
- Anxiety
- Depression
- Mood changes
- Suicidal thoughts
- Suicidal behavior
- Emotional distress
Allergic and Injection-Related Risks
- Injection site pain
- Bruising
- Redness
- Swelling
- Infection
- Allergic reactions
- Severe allergic reactions (anaphylaxis)
Additional Risks
- Muscle loss
- Excessive weight loss
- Hair loss
- Fatigue
- Medication interactions
- Unknown long-term risks
- Serious injury, hospitalization, disability, or death
I understand that this list is not exhaustive and that other known or unknown side effects may occur.
PATIENT RESPONSIBILITIES
I agree that I will:
- Provide accurate and complete medical information.
- Disclose all medications, supplements, and medical conditions.
- Follow all prescribing provider instructions.
- Immediately report any side effects or adverse reactions.
- Seek emergency medical treatment when necessary.
- Contact my prescribing provider regarding any medical concerns.
NO GUARANTEE OF RESULTS
I understand that no specific outcome, weight loss amount, health improvement, or treatment result has been promised or guaranteed.
Individual results vary significantly.
ASSUMPTION OF RISK
I voluntarily choose to participate in treatment recommended by my prescribing healthcare provider.
I acknowledge that I understand the risks, benefits, alternatives, and uncertainties associated with treatment and voluntarily assume all risks associated with such treatment.
RELEASE AND HOLD HARMLESS AGREEMENT
To the fullest extent permitted by law, I release, waive, discharge, and hold harmless Sands Weight Loss & Wellness, its owners, officers, employees, contractors, affiliates, consultants, agents, successors, and assigns from any and all claims, demands, damages, losses, liabilities, costs, expenses, or causes of action arising out of or relating to:
- My medical treatment;
- Prescription decisions made by healthcare providers;
- Medication side effects;
- Adverse events;
- Complications from treatment;
- Medication effectiveness or lack of effectiveness;
- Injuries, illness, disability, or death allegedly related to treatment.
I understand that Sands does not manufacture, prescribe, dispense, or direct the use of medications and is not responsible for medical decisions made by licensed healthcare providers.
ACKNOWLEDGMENT
By signing below, I acknowledge that:
- I have read and understand this document.
- I have had the opportunity to ask questions.
- I understand the risks associated with treatment.
- I understand Sands Weight Loss & Wellness is not my healthcare provider.
- I understand all medical treatment decisions are made by licensed healthcare providers.
- I voluntarily consent to participate in treatment.