La Flaca Consents

I authorize Lev Paukman, MD and Manhasset Med Spa to treat me so that I can lose weight and maintain a healthy body weight. I understand that my treatment may involve, but not be limited to, the use of appetite suppressants for more than 12 weeks and in higher or lower doses than stated in the appetite suppressant labeling. I understand that the use of the appetite suppressants in patients with BMI less than 27, for more than 12 weeks and in higher doses than stated in the appetite suppressant labeling involves some risks. The more common risks include nervousness, sleeplessness, and headache, an ache, dry mouth, weakness, tiredness, psychological problems, medication allergies, high blood pressure, rapid heartbeat, and heart irregularities. Less common, but more serious risks include primary pulmonary hypertension and heart disease.

I understand that it is my responsibility to follow the instructions carefully and to report to Lev Paukman, MD, any significant medical problems that I think maybe related to my weight control program as soon as reasonably possible. I understand that continuing me on appetite suppressants will depend on my progress in weight loss and weight maintenance. I understand that other ways and programs can assist me in losing weight and maintaining a healthy weight. I understand that a balanced calorie counting program without the appetite suppressant would likely prove successful if followed closely. I understand that much of the program’s success will depend on my efforts and that there are no guarantees or assurance 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. I have discussed with Lev Paukman, MD, various treatment options, and feel adequately informed concerning the risks associated with the proposed treatment.