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I request injections of HCG along with strict dietary restrictions for the purpose of weight loss. I understand that as part of the program, I will be given a limited physical orientation with supporting materials and will be instructed on how to self-administer the injections. I understand that initial blood tests are necessary to rule out any conditions that may disqualify me from participating in the program.
I acknowledge that HCG is not FDA approved for weight loss and that its use in this context is considered “off-label.” I understand there is no conclusive medical evidence to support the use of HCG for weight reduction. I agree that I remain under the care of another licensed medical provider for all unrelated medical conditions. Sarah Godsave, FNP-C, may work in conjunction with, but not as a replacement for, my primary care provider or other specialists.
Prior to beginning treatment, I have fully disclosed all relevant medical conditions or diseases, including but not limited to: pregnancy, attempting to conceive, breastfeeding, gallbladder disease, diabetes, autoimmune disease, HIV, heart disease, liver or kidney disease, uncontrolled high blood pressure, seizure disorders, blood disorders (such as anemia, thalassemia, or hemophilia), asthma, emphysema, and any history of stroke or cancer. These contraindications have been thoroughly discussed with me. I understand that if I fail to disclose a condition, I release the provider and Down-to-Earth Wellness Center from any resulting liability.
Although HCG is generally well tolerated, I understand that risks may include, but are not limited to: Ovarian Hyperstimulation Syndrome (a potentially life-threatening condition), arterial thromboembolism, blood clots, risk of pregnancy and multiple births, gynecomastia in men, overstimulation of the ovaries, acne, fatigue, mood changes, skin irritation or rash, fluid retention, hair loss, prostate hypertrophy, difficulty breathing, collapse, or death. I understand that these and other unknown risks may occur.
I acknowledge that HCG is contraindicated during pregnancy and breastfeeding. I agree to inform Sarah Godsave, FNP-C if I am currently pregnant, trying to conceive, or become pregnant during the course of treatment. I understand that because HCG is used in fertility treatments, I may have an increased likelihood of becoming pregnant while using it. I also understand that multiple forms of birth control should be used while undergoing HCG treatment, and that HCG is contraindicated for women who use an IUD as their form of birth control.
By signing the Consent & Authorization Summary Signature Page, I agree to report any complications or concerns to my medical provider during treatment. I understand that failure to follow dosing and dietary guidelines may increase the risks and negatively impact results. If I fail to follow the medical recommendations provided, I release the provider and facility from liability for any outcomes that may arise.
I understand that I may discontinue participation in the program at any time. While complications are not anticipated, I agree to immediately contact Down-to-Earth Wellness Center if I experience any adverse reactions. In the case of an emergency, I will go to the nearest emergency facility.
If there are any changes in my health status, medications, or any other information relevant to this treatment, I will notify Sarah Godsave, FNP-C immediately.
By signing the Consent & Authorization Summary Signature Page, I have read and understand this consent form in full. All of my questions have been answered to my satisfaction, and I agree to release the provider and Down-to-Earth Wellness Center from any liability associated with this procedure.