La Flaca Consents

I request injections of HCG along with strict dietary restrictions for the purpose of weight loss. I understand that as part of the program, I will be given a limited physical orientation to the program with supporting materials, and I will be instructed on how to administer the injections myself. I understand that initial blood tests will be necessary to rule out any conditions that would disqualify me from the program. I will obtain these from my own physician or have them ordered through Lev Paukman, MD. I understand HCG is not FDA approved for weight loss as this application is considered “off-label use.” I understand there is no medical evidence to support the use of HCG for this purpose. I agree that I am and will be under the care of another medical provider for all other conditions. Lev Paukman, MD can work in conjunction with, but cannot replace, my regular primary care physicians, such as general practitioners or other specialists in family medicine or internal medicine. I understand Lev Paukman, MD can only prescribe HCG and medication necessary for this treatment, and all other health matters should be through my regular physician(s). Before my treatment, I have fully disclosed any medical conditions or diseases such as pregnancy, trying to get pregnant, breastfeeding, history of gallbladder disease, diabetes, autoimmune diseases, HIV, heart disease, liver disease, kidney disease, uncontrolled high blood pressure, seizure disorders, blood disorder (anemia, thalassemia, hemophilia, etc.) emphysema or asthma, and any history of stroke or cancer. These contraindications have been fully discussed with me. If I fail to disclose any medical condition that I have, I release the doctor and facility from any liability associated with this procedure.

While HCG is generally free of negative side effects, there is the possibility of the following:

• Risk of multiple pregnancies (twins, triplets, quadruplets, etc.)
• Overstimulation of the ovaries causing the production of many ova (eggs) in women
• Acne
• Tiredness
• Irritation or skin rash in the area of use
• Excessive fluid retention in the body tissues, resulting in swelling (edema)

For female only

I understand HCG treatments may involve these risks and other unknown risks: I understand that use of HCG is absolutely contraindicated during pregnancy and breastfeeding. I understand that it is my responsibility to inform Lev Paukman, MD if I am pregnant, if I am trying to become pregnant or if I become pregnant during these treatments. I understand that HCG is used in infertility treatments. Therefore, I have an increased chance of pregnancy while on HCG. Multiple birth control methods should be used while on HCG. However, HCG is contraindicated for women using IUD for birth control. Therefore, I agree to use condoms and/or abstinence as a birth control method for the duration of the diet. I agree to immediately report any problems that might occur to my medical provider during the treatment program.

I further understand that not complying with the dosage recommendations and dietary restrictions could increase risks and alter my results from the program. If I do not follow these recommendations and limitations, I agree to release the doctor and facility from any liability arising from this. I understand that I may quit the program at any time. While adverse side effects or complications are not expected, if an illness does occur, I understand that I need to contact Lev Paukman, MD immediately. If I experience an emergency situation, I understand that I need to go to an emergency facility. I understand that if there are any changes in my medical history or any changes in my medications or any other changes relevant to this procedure, I will advise Lev Paukman, MD, at that time.