I. Procedure And Alternatives:
(patient or patient’s guardian) authorize
Dr. George C. Stege III to assist me in my weight reduction efforts. I understand my treatment may
involve, but not be limited to, the use of appetite suppressants for more than 12 weeks and when indicated
in higher doses than the dose indicated in the appetite suppressant labeling.
2. I have read and understand my provider’s statements that follow:
“Medications, including the appetite suppressants, have labeling worked out between the makers of
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 based on shorter term studies (up to 12 weeks) using the dosages indicated in the labeling.
“As a bariatric provider, I have found the appetite suppressants helpful for periods far in excess of 12
weeks, and at times in larger doses than those suggested in the labeling. As a provider, I am not required to use the medication as the labeling suggests, but I do use the labeling as a source of information along with my own experience, the experience of my colleagues, recent longer term studies and recommendations of university based investigators. Based on these, I have chosen, when indicated, to use the appetite suppressants for longer periods of time and at times, in increased doses.
“Such usage has not been as systematically studied as that suggested in the labeling and it is possible, as with most other medications, that there could be serious side effects (as noted below).
“As a bariatric provider, I believe the probability of such side effects is outweighed by the benefit of the appetite suppressant use for longer periods of time and when indicated in increased doses.
However, you must decide if you are willing to accept the risks of side effects, even if they might be serious, for the possible help the appetite suppressants use in this manner may give.”
3. I understand it is my responsibility to follow the instructions carefully and to report to the provider
treating me for my weight any significant medical problems that I think may be related to my weight
control program as soon as reasonably possible.
4. I understand the purpose of this treatment is to assist me in my desire to decrease my body weight and to maintain this weight loss. I understand my continuing to receive the appetite suppressant will be dependent on my progress in weight reduction and weight maintenance
5. I understand there are other ways and programs that can assist me in my desire to decrease my body weight and to maintain this weight loss. In particular, a balanced calorie counting program or an exchange eating program without the use of the appetite suppressant would likely prove successful if followed, even though I would probably be hungrier without the appetite suppressants.
II. Risks of Proposed Treatment:
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 in the labeling involves some risks and hazards. The more common include: nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, 7 psychological problems, medication allergies, high blood pressure, rapid heart beat and heart irregularities. Less common, but more serious, risks are primary pulmonary hypertension and valvular heart disease. These and other possible risks could, on occasion, be serious or fatal.
III. Risks Associated with Being Overweight or Obese:
I am aware that there are certain risks associated with remaining overweight or obese. Among them
are tendencies to high blood pressure, to diabetes, to heart attack and heart disease, and to arthritis of the joints, hips, knees and feet. I understand these risks may be modest if I am not very much overweight but that these risks can go up significantly the more overweight I am.
IV. No Guarantees:
I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I also understand that I will have to continue watching my weight all of my life if I am to be successful.
V. Patient’s Consent:
I have read and fully understand this consent form and I realize I should not sign this form if all items
have not been explained, or any questions I have concerning them have not been answered to my
complete satisfaction. I have been urged to take all the time I need in reading and understanding this form and in talking with my provider regarding risks associated with the proposed treatment and regarding other treatments not involving the appetite suppressants. I voluntarily agree to have one (1) prescribing provider for controlled substances, to use only one (1) pharmacy to fill prescriptions for controlled substances, not to have early refills on the prescriptions for controlled substances, and to provide full disclosure of other medications (narcotics) taken.
WARNING
IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THE PROPOSED TREATMENT, OR ANY QUESTIONS WHATSOEVER CONCERNING THE PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK YOUR PROVIDER NOW BEFORE SIGNING THIS CONSENT FORM.
VI. PROVIDER DECLARATION:
I have explained the contents of this document to the patient and have answered all the patient’s related questions, and, to the best of my knowledge, I feel the patient has been adequately informed concerning the benefits and risks associated with the use of the appetite suppressants, the benefits and risks associated with alternative therapies and the risks of continuing in an overweight state. After being adequately informed, the patient has consented to therapy involving the appetite suppressants in the manner indicated above.
