If you have any questions, please feel free to ask us. Please sign to acknowledge your understanding:

If you are late or miss your appointment, you may be subject to a $50 fee. Rescheduling appointments is offered one time free of charge. After that, Reset Wellness, PLLC reserves the right to charge for your visit 24 hours before the visit is scheduled to occur.
Services must be paid for before the time of service.

While we do not require any commitment, our providers do recommend you stick with the program for at least 3 months to see the results you are looking for! Oftentimes, significant loss will happen with higher doses and that can’t be achieved before 3 months. We are here to make this a success for you.

Please also note that we do not automatically ship medication without a visit. Medication is ordered during visits when requested and needed.

Health insurance typically does not cover services provided at Reset Wellness, PLLC.  If you want to seek insurance reimbursement, we would be happy to provide you itemized invoices that you can submit to your insurance company.

I agree that I will take my medications as prescribed. I agree to follow my medical provider’s instructions. I also agree that I will not sell or share my prescriptions to other individuals.

I understand that treatments used at Reset Wellness, PLLC might not be considered a medical necessity. Treatments rendered are for the purpose of improving your quality of life through hormone restoration, nutritional, and supplemental counseling, and weight loss or weight maintenance treatment.

I agree that if I am having any side effects or become sick, that I will follow up with my primary care provider or go to an urgent care or emergency department immediately.

I acknowledge that Reset Wellness, PLLC and our providers are not my primary care provider. I agree that I will continue with routine care through my primary care provider and notify them of treatments prescribed at Reset Wellness, PLLC.

I understand that there are no refunds for services or products rendered. We cannot accept used medications once they have been dispensed per state regulation.
 

If your vial is damaged or mishandled or incorrect dose is administered resulting in running out early, you will need to cover the cost of additional medication.

I understand that having an appointment with Reset Wellness, PLLC does not necessarily entitle me to being issued a prescription for hormone replacement, weight loss medication, or additional medications. Every individual is different, and it is at the medical provider’s discretion to issue a prescription. If you are not prescribed a medication, the $50 initial visit fee is waived.

I understand that I must maintain my follow up appointments to remain on treatment. It is important that lab work is monitored regularly for safety purposes. It is at our providers discretion to provide and require additional testing.

I acknowledge that I have been advised of the risks and benefits of treatment. I also acknowledge that I have been advised of possible complications and side effects. I understand the risks, benefits, complications, and side effects of treatment.

I do not hold any medical practitioner of Reset Wellness, PLLC responsible for performing age-related preventive care. I agree that I will follow up with my primary care provider to obtain these screenings and I hold all providers of Reset Wellness, PLLC harmless if an adverse event occurs during my treatment. I will ensure that my primary care provider provides the results of such screenings to Reset Wellness, PLLC as this could change the treatment prescribed to me.

I understand that refunds of medicines are not offered under any circumstances as no healthcare provider can reasonably predict response, intolerance, or lack of response to any specific weight management or hormonal replacement treatment. Medications cannot be returned.

I agree to indemnify, defend, protect, and hold harmless the medical providers or staff employed or contracted by Reset Wellness, PLLC and their respective officers, directors, employees, stockholders, assigns, successors and affiliates (Indemnified Parties) from, against and in respect of all liabilities, losses, claims, damages, judgements, settlement payments, deficiencies, penalties, fines, interest and costs, expenses suffered, sustained, incurred or paid by the indemnified parties, in connection with, results from or arising out of, directly or indirectly, the medical providers employed by Reset Wellness, PLLC rendering medical care, services, advice, and/or treatment, my failure to disclose all relevant information regarding my medical and physical condition, acts or omissions, the medical providers employed or contracted by Reset Wellness, PLLC ; harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by the medical providers employed by Reset Wellness, PLLC. I am aware of the potential side effects associated with weight loss therapy, accept all the risks involved in taking the medication and will not seek indemnification or damages from the indemnified parties.

 

Informed Consent for Medical Management Weight
Loss Therapy

I acknowledge that I am voluntarily entering into a medically managed weight loss program with Reset Wellness, PLLC. I fully realize that entering any program involving weight reduction, which includes moderate calorie restriction, exercise, and medications, involves potential risks and side effects. The risks include but may not be limited to the following:
Please note that most of these do not apply to GLP1 medications such as semaglutide but do apply to phentermine and/or bupropion.

● Cardiovascular (heart or blood pressure): These problems may include heart palpitations, irregular beats, or rapid heartbeat. These effects are usually mild but can result in serious problems including heart attack or stroke. Also, these medications may increase blood pressure, which if left untreated can lead to heart attack or stroke. If you discontinue the weight loss medication, the elevated blood pressure usually resolves. For this reason, if you are on blood pressure medications you are required to monitor your blood pressure daily and discontinue medications if blood pressure rise, your heart rate increases, or you feel palpitations.

● Sudden Death: Patients with morbid obesity, particularly those with hypertension, heart disease, or diabetes, have a statistically higher chance of suffering sudden death when compared to normal weight people without such medical problems. Rare instances of sudden death have occurred while obese patients were undergoing medically supervised weight reduction, though no cause-and-effect relationship with the diet has been established. The possibility cannot be excluded that some undefined or unknown factor in the treatment program could increase this risk in an already medically vulnerable patient.

● Reduced Potassium Levels: The calorie level you will be consuming is 800 or more calories per day and it is important that you consume the calories which have been prescribed in your diet to minimize side effects. Failure to consume all of the food and fluids, nutritional supplements or taking a diuretic medication (water pill) may cause low blood potassium levels or deficiencies in other nutrients. Low potassium levels can cause serious heart irregularities. When someone has been on a reduced calorie diet, a rapid increase in calorie intake, especially overeating or binge-eating, can be associated with bloating, fluid retention, disturbances in electrolytes, or gallbladder attacks and abdominal pain. For these reasons, following the diet carefully and following the gradual increase in calories after weight loss is essential.

● Gall Bladder Disease: Any program resulting in rapid weight loss may precipitate the formation of gallstones, which could lead to cholecystitis (inflammation of your gallbladder), which is a medical urgency or emergency and could require surgery. This is typically because of the rapid weight loss, not the medications you are taking. Symptoms include right upper abdominal pain, abdominal just below your ribs, nausea, and vomiting.

● Pancreatitis: Pancreatitis, or an infection in the bile ducts, may be caused by gallstones or the development of sludge or obstruction in the bile ducts. The symptoms of pancreatitis include pain in the left upper abdominal area, nausea, and fever. Pancreatitis may be precipitated by binge-eating or consuming a large meal after a period of dieting. Also associated with pancreatitis is long-term abuse of alcohol and the use of certain medications and increased age. Pancreatitis may require surgery and may be associated with more serious complications and death.

● Psychiatric: There are reported cases of “hysterical or psychotic reactions” associated with the use or discontinuation of some of the drugs utilized for weight loss purposes. These reactions are extremely rare.

● Men over 40 and post-menopausal women in general, and patients with risk factors for cardiovascular disease should have a cardiovascular evaluation before entering a medically managed weight loss program. This may include an ECG, a stress test, or other testing procedures, as per the discretion of a cardiologist. If you are over the age of 40, post-menopausal (female), smoke, have a history of high blood pressure, high cholesterol or you are diabetic, you acknowledge that you have had a cardiac evaluation and that you have been cleared medically prior to starting this weight loss program.

● Common, but troublesome side effects may include but not be limited to dry mouth, palpitations, “speedy” feeling, headaches, sleeplessness., Rash, fever, nausea, vomiting, allergic reactions, decreased insulin sensitivity, flushing, headache, fatigue, lightheadedness, abdominal cramping, joint pain, fluid retention, and additional side effects not listed that will be discussed during your evaluation with providers at Reset Wellness, PLLC. These side effects are generally rare, and most patients tolerate treatment without an issue.
 
● Drug interactions may occur if other medications are taken. Therefore, I will check with my prescribing medical provider before starting the program if I am taking other medications.

● Pregnancy (Females Only). If you become pregnant, inform your physician immediately. Your diet must be changed promptly to avoid further weight loss because a restricted diet could be damaging for a developing fetus. You must take precautions to avoid becoming pregnant during weight loss medication therapy.

● The use of medications for weight management is indicated for those patients who have a BMI of 30 or higher or a BMI of 27 or higher with other medical conditions such as high blood pressure, diabetes, or high cholesterol. Prescribing medications for patients not fitting these criteria, is considered “off label” and not “FDA approved.” Therefore, the potential risks vs. benefits may be great. For patients not fitting the BMI criteria for use of weight loss medication, you are acknowledging that:

● You have put forth a true effort to lose weight through diet and exercise over the past 6 months and have still not achieved your weight loss goals.

● That your inability to lose weight is causing significant emotional distress

● You are choosing to enter this medically managed weight loss program voluntary and hold harmless providers of Reset Wellness, PLLC for use of such medications.

●You acknowledge that alcohol and illicit drug use is prohibited in the program. Drugs like cocaine and amphetamines when used in conjunction with appetite suppressants and other medications prescribed could cause in serious injury or death. The use of alcohol will also affect your results.

●I understand that the provider and I will determine what my daily caloric intake will be at my initial visit.

●I acknowledge that I understand that the amount of weight loss varies from patient to patient, and is, to a large extent dependent on each patient’s personal motivation and commitment to their diet and exercise plan. No claims as to efficacy or specific amount of weight loss is either expressed or implied. I understand the importance of routinely following up with Reset Wellness, PLLC to monitor my progress during treatment. I understand this is vital to the safety of the treatment program and certify that I will be returning monthly as prescribed.

●I hereby authorize any provider at Reset Wellness, PLLC to evaluate me for admission into weight management program and treat me accordingly. I consent to obtaining blood work before treatment if deemed necessary. I certify that I am signing this under my free will and am competent to make my own medical decisions.

●I have reviewed the mentioned risks and have determined the benefits outweigh the possible risks associated with medically managed weight loss therapy with Reset Wellness, PLLC. I release any claim in court or any type of complaint that could result from treatment by a provider of Reset Wellness, PLLC and will not hold liable any provider or staff of Reset Wellness, PLLC.

●I understand that treatment modalities utilized by Reset Wellness, PLLC might not be supported by scientific/medical literature and could be seen as experimental or based off anecdotal claims. Many medical providers, including endocrinologists, surgeons, family practice doctors, etc., might see these types of treatments as not medically necessary. I also understand that some of the medications being utilized within Reset Wellness, PLLC medically managed weight loss program are considered to be used “off label” and might not be FDA approved for weight loss purposes.

●By signing below, I acknowledge that I have had an opportunity any concerns and the above information with my provider at Reset Wellness, PLLC, either in person or by telephone conversation. I consent to the treatment being offered to me by provider at Reset Wellness, PLLC and I am satisfied with the explanation. I acknowledge that I have read or have had read to me the above consent and understand the information presented.
 

 

 

Risks and Benefits Acknowledgement

I recognize the potential risks of this treatment program, and I also understand the potential benefits of weight loss, which may include:
Decreased risk of heart attack.
Decreased risk of adult onset diabetes mellitus.
Decrease risk to developing arthritis or developing musculoskeletal conditions that are caused by excessive weight.
Increased emotional and psychological well-being.
Decreased risk of developing certain types of cancer.
I acknowledge that the medically managed weight loss program recommended to me by Reset Wellness, PLLC. is just one of multiple strategies to reduce weight. Alternative treatment options include:
Diet and exercise alone without medications.
The use of other kinds of medications to achieve appetite suppression.
Non-medical weight loss programs like Weight Watchers.
Bariatric Surgery.

My Obligations and Representations
Any questions I have regarding this treatment have been answered to my satisfaction. I understand that I will be responsible for administering the medications prescribed to me if I do not have them administered to me in clinic. I also promise to comply with the dosages and frequency of medications prescribed to me.

I certify that I am under the regular care of a primary care provider for any other conditions I might have or am found to have. I will consult with my primary care provider or specialist regarding any other condition I might have. I understand that if I do not have a primary care provider, I will be encouraged to seek one out. I acknowledge that I am seeking care at Reset Wellness, PLLC for medically managed weight loss services. I acknowledge I am not wanting to establish primary care with Reset Wellness, PLLC and I am here for specialized care including weight loss therapy, diet counseling, exercising counseling, (additional services you have) etc.

Regaining Weight Acknowledgement:
There is a Risk of Regaining the Weight you have lost. Obesity is a chronic condition, and many overweight individuals who lose weight have a tendency to regain all or some of it back over time. Factors which favor maintaining weight loss include exercise, adherence to a calorie diet that is low-calorie, nutritious, and full of lean proteins and vegetables, and planning a strategy for coping with weight regain before it occurs. Successful treatment may take months or even years. Utilizing medications to assist you in your weight loss goals in addition to diet and exercise could result in weight coming back if you do not maintain eating a healthy diet and exercising. Additionally, if you have had fluctuations in your weight in the past, it may be more difficult to maintain the weight you lose.
​
Telehealth Policy: 
PLEASE READ EACH SECTION CAREFULLY. YOU MAY REQUEST A COPY OF THIS FORM FOR YOUR OWN RECORDS.

Introduction: Telemedicine involves the real-time evaluation, diagnosis, consultation on and treatment of a health condition using advanced telecommunications technology, which may include the use of interactive audio, video or other electronic media. As such, telemedicine allows the provider to see and communicate with the patient in real time. There are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand I can ask questions and seek clarification of the procedures and telemedicine technology at any time.

Consent for treatment: I voluntarily request Reset Wellness, PLLC and its nurse practitioners, nurses, associates, technical assistants and other health care providers as it may deem necessary (collectively “Practice”) to participate in my medical care through the use of telemedicine. 

I understand that Practice (i) may practice in a different location than where I present for medical care, (ii) may not have the opportunity to perform an in-person physical examination, and (iii) rely on information provided by me. I acknowledge that it is my responsibility to provide information about my medical history, condition and care that is complete and accurate to the best of my ability. I further acknowledge my failure to accurately and completely relay information about my medical history, condition and care may adversely impact Practice’s advice, recommendations,or decisions about my care. I understand that the practice of medicine is not an exact science and that no warranties or guarantees are made to me as to result or cure.

I understand that if Practice determines in its reasonable professional judgment that telemedicine services will not adequately address my medical needs, I may be required to complete an in-person medical evaluation. I also understand that in the event the telemedicine session is interrupted due to a technological problem or equipment failure, alternative means of communication may be implemented, or an in-person medical evaluation may be necessary. Finally, if I experience an urgent matter after a telemedicine session, such as a bad reaction to a treatment, I should alert my treating physician and, in the case of emergencies, dial 911 or go to the nearest hospital emergency department.

Right to withdraw consent: I understand that I have the right to withdraw my consent to the use of telemedicine in the course of my care at any time.

I have read this Telemedicine Consent in its entirety and agree to be bound by all of its terms and conditions as described above. I acknowledge and agree that I have been given the opportunity to ask any questions and have either (i) declined the opportunity to do so, or (ii) had all my questions answered to my satisfaction.