authorize Dr. George C. Stege III, Louisville Center for Weight Loss. and whomever they designate as their assistants, to help me in my weight reduction efforts. I understand that my program may consist of a balanced deficit diet, a regular exercise program, instruction in behavior modification techniques, and may involve the use of appetite suppressant medications. Other treatment options may include a very low calorie diet, or a protein supplemented diet. I further understand that if appetite suppressants are used, they may be used for durations exceeding those recommended in the medication package insert. It has been explained to me that these medications have been used safely and successfully in private medical practices as well as in academic centers for periods exceeding those recommended in the product literature
I understand that any medical treatment may involve risks as well as the proposed benefits. I also understand that there are certain health risks associated with remaining overweight or obese. Risks of this program may include but are not limited to nervousness, sleeplessness, headaches, dry mouth, gastrointestinal disturbances, weakness, tiredness, psychological problems, high blood pressure, rapid heartbeat, and heart irregularities. These and other possible risks could, on occasion, be serious or even fatal. Risks associated with remaining overweight are tendencies to high blood pressure, diabetes, heart attack and heart disease, arthritis of the joints including hips, knees, feet and back, sleep apnea, and sudden death. I understand that these risks may be modest if I am not significantly overweight, but will increase with additional weight gain.
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 obesity may be a chronic, life-long condition that may require changes in eating habits and permanent changes in behavior to be treated successfully.
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 to me. My questions have been answered to my complete satisfaction. I have been urged and have been given all the time I need to read and understand this form.
If you have any questions regarding 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.
Welcome to our weight loss program! The program consists of three parts: diet, exercise, and medication.
We recommend a low fat reduced calorie diet. We will provide you with additional information on a low fat diet, and the provider will give you specific recommendations on how many fat grams you should eat each day. We do recommend three well balanced meals a day with no between meal snacking.
We recommend aerobic exercise to help you lose weight. We recommend walking as the best exercise for most patients. The YMCAs offer excellent exercise programs. We recommend at least 30 minutes of aerobic exercise three times a week for cardiovascular fitness. If you are extremely overweight, water aerobics are another alternative.
Several types of appetite suppressants are available to assist you in losing weight. These medications will only suppress your appetite; to lose weight you must eat less. The provider will prescribe the one that is most appropriate for you. We have additional information on the medications available on request. The provider will answer any questions you have about the risk and benefits of using medication. In order to reach a healthy weight, it may be necessary to use medication in ‘off-label’ duration, indication, or combinations. Vitamins and other health supplements such as B12, B12 Lipo, and DHEA may be recommended that many people have found helpful but are without proven benefit. We do recommend daily multivitamins with vitamins A, B complex, C, D, E and K, and minerals calcium and iron.
In order to ensure your safety in taking any medication, it is important that we obtain a complete medical history and perform a physical exam. Some medical conditions such as high blood pressure or heart disease such as angina preclude the use of medication. Also, if you have a history of drug or alcohol abuse it is not safe for you to take medication. If you are pregnant or think you may be pregnant you must not take any medication. You must also let us know if you are allergic to any medication. You must not exceed the prescribed dose of any medication. Doing so would put you at risk of heart attack, stroke, or death. You also should check with the office before taking any over the counter medicine with prescription medication. You must let us know if you are taking any prescription medicine from any other providers. While participating in our diet program you must not see any other provider for similar medication as this may put you at risk for serious side effects or drug dependency and may be against the law. Regulations require that you fill your prescriptions at one pharmacy, and they can’t be refilled early. Also be aware that it is against the law to sell or give your medication to any other person. If you have taken any diet
medication in the past you must also inform us of this. We will provide you with copies of your lab results and EKG to take to your Primary Care Provider (PCP) for evaluation and treatment. Dr. Stege is a specialist board certified by the American Board of Bariatric Medicine. He will work with your PCP to help you. All blood test, urine tests, and EKGs will be given to you to take to your PCP for his evaluation and any necessary treatment. We recommend annual blood work. Dr Stege was also board certified in Family Practice by the American Board of Family Practice, and is a Fellow of the American Academy of Family Practice. While Dr. Stege may help you with refills or minor medical problems, he will not be functioning as your PCP unless specifically requested to do so in writing. Being overweight is a risk factor for sleep apnea and we recommend sleep studies if you are having any sleep difficulties.
To be eligible for medication you must be overweight. Being significantly overweight increases your risk of many serious medical problems. The provider will calculate your ideal weight based on your height, your frame size, and your percentage of body fat. You must also have tried to lose weight on your own first by diet and exercise for at least six months. I acknowledge that I have tried to lose weight on my own by diet and exercise for at least six months. To continue medication you must lose weight. If you experience any side effects or problems please call the office. Dry mouth, constipation, mild elevations of heart rate and slight nervousness are the most common side effects and are not of concern. Shortness of breath, chest pain, leg swelling, fainting spells, or elevated blood pressure should be reported immediately.