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Consent Form

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Weight Loss Informed Consent

I, ___________________________________, authorize my Sei Tu Bella Aesthetics provider or advanced practice clinician (s) and/or whomever may be designated as the medical assistant(s),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 behavioral modification techniques, and may involve the use of appetite suppressant medications. Other treatment options may include a very low caloric diet, or a protein supplemented diet. I further understand That if appetite suppressants are prescribed, they may be used for durations exceeding those recommended in the medication package insert. It has been explained to me to my complete satisfaction 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 medication product literature.

I have been provided a list of the medications that will be apart of my weight loss problem and have the means to review various side effects, medication interactions, adverse effects ext regarding the medication and I have been provided for my weight loss journey. I understand that it is my responsibility to review any new treatment plan with the primary care provider of choice. I understand that results of the program are not guaranteed and the program is non refundable.

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 associated with remaining overweight are tendencies to have high and increasing higher 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 made to me that the program will be successful. I also understand that obesity may be a chronic, life-long condition that may require drastic changes in eating habits and permanent changes in behavior to be treated successfully. I understand that failing to show up for an appointment I have scheduled, without calling or contacting Sei Tu Bella Aesthetics ahead of time, represents a disruption to operation of the clinic. Failure to show up (“No-Show”) for a pre appointed Follow Up Visit, or failure to cancel at least one full business day prior ‐ to a scheduled visit will result in need to pay for the missed visit and pre-pay the next Medical Weight Loss Visit. I have read and fully understand this consent form and “no show” policy. I have had all of my questions answered to my complete satisfaction. I have been given
all the time that I need to carefully read and understand this form.

________ (Initials) By my initials, I acknowledge that I have had an opportunity to review Sei Tu Bella Aesthetics General Consent for Treatment Policy and also acknowledge that I should request a copy, a copy will be provided to me. I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition that may have a bearing on this procedure.I consent and authorize Sei Tu Bella Aesthetics , LLC, and it’s affiliates to perform the procedure listed on me. I certify that I have read this entire informed consent and I understand and agree to the information provided in the form. My questions regarding the procedure have been answered satisfactorily. I hereby release Heather Merlo, APRN, FNP-C, Medical Director Dr. Fernando Jara, Sei Tu Bella Aesthetics LLC from all liabilities associated with this procedure. This consent is valid for all of my treatments in the future as well.

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