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They can cause dry mouth, stomach, bowel and bladder problems, constipation, diarrhea, impotence, hives, sweating, eye irritation, muscle aches, numbness, chills, fever and many other symptoms. They interact powerfully with certain other drugs. In combination with some medications (especially blood pressure medications, antidepressants, alcohol and anesthetics) they could cause sudden death. They never be taken by children, by persons with glaucoma, or during pregnancy or nursing. There is a chance that these drugs could should be harmful to a fetus (although this is not known for sure). There is a chance that some of these drugs may be habit-forming. Researchers are investigating reports that some ? perhaps all ? of these medications may cause brain or nerve damage, even during short-term use. This has been seen in laboratory animals. Some researchers believe that while there may be some changes in brain cells, they don?t really cause any problems in humans. However, other researchers believe that the brain damage is real and serious. But no one really knows what happens with long-term use in humans. Use of these drugs for more than three months is associated with an increase in the risk of primary pulmonary hypertension, a rare lung disorder which is often fatal. This disease occurs in about 1-2 people per million in the general population; however, primary pulmonary hypertension has been seen in 23-46 per million people who use diet pills. It is possible that in the future, new hazards will be discovered that will create concern about your having taken diet medication. Keep this in mind before you decide to start. We cannot predict what success you may have with diet medications.

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 hips or other joints. I understand that 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. 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 remain successful. PATIENTS 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 doctor regarding other treatments not involving appetite suppressants. WARNING IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THE PROPOSED TREATMENT, OR ANY QUESTION WHATSOEVER CONCERNING THE PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK YOUR DOCTOR NOW BEFORE SIGNING THIS CONSENT FORM.

Patient Name:

Patient ID:

Patient Signature:

Date: ___________

Witness Signature:

Date: ___________

Provider Acknowledgement: ______________________

Date: ___________

Transform your Life

Transform Your Life: Medical Weight Loss Book  
Transform Your Life: Medical Weight Loss Book  

The Transform Your Life: Medical Weight Loss Book was given to patients after a bariactric exam and upon their initial visit with a nutritio...