Medical Consent

Last Updated: [September 10, 2024]

IMPORTANT NOTICE: THIS IS NOT A SUBSTITUTE FOR EMERGENCY MEDICAL CARE. IN THE EVENT OF A MEDICAL EMERGENCY, PLEASE CALL 911 OR SEEK IMMEDIATE IN-PERSON MEDICAL ATTENTION.

Introduction

Jeffrey Olsen, MD (referred to as “we,” “us,” or “our”) provides weight management services through our clinic at www.medicationandweightloss.com. Our program includes personalized consultations, medication assistance with semaglutide or tirzepatide, and tailored nutrition and exercise plans. By accessing our services, you agree to the terms outlined in this Medical Consent

### Service Overview

Our program provides a comprehensive approach to weight loss, including:

- In-home doctor consultations and follow-up visits.

- Online appointments with Dr. Olsen.

- Access to prescribed medications shipped directly to your home.

### Expected Benefits

- Improved access to weight loss support.

- Customized treatment plans to help you achieve your health goals.

- Continuous monitoring and adjustments based on your progress.

### Possible Risks

While our services offer significant benefits, there are potential risks, including but not limited to:

- Adverse reactions to prescribed medications.

- The need for ongoing monitoring and adjustments to your weight loss plan.

- Inability to participate in the program due to specific health conditions.

### Patient Consent

By consenting to this medical form, you acknowledge and understand the following:

1. You have the right to ask questions about your treatment before, during, and after your consultation.

2. You understand that the medications and treatments provided are tailored to your individual health needs.

3. You may withdraw your consent to participate in this program at any time without affecting your right to future care or treatment.

### Who Qualifies for the Program?

Eligibility for our program will be determined based on health assessments conducted by Dr. Olsen and his Medical Team. Certain health conditions may disqualify individuals from receiving prescriptions for semaglutide or tirzepatide. If you have any of the following conditions, please contact us before scheduling your appointment:

- BMI under 27

- History of pancreatitis

- Medullary thyroid carcinoma

- Severe kidney disease

- Pregnancy or breastfeeding

- Other relevant health concerns

### Financial Policy

To render services, we require a credit card to be kept on file. You agree to pay any remaining balances for services rendered in full. By providing your credit card information, you authorize Jeffrey Olsen, MD, to process payments on your behalf, including any unpaid balances due for consultations and medications. Fee schedules and receipts for all professional services are available upon request.

You acknowledge that our programs are auto-renewing, and you consent to being automatically charged for any program in which you participate unless you explicitly request cancellation one week prior to your payment being processed. Please note that after the initial doctor consultation there are no refunds or exchanges for services rendered.

### Privacy and Confidentiality

We are committed to protecting your privacy and the confidentiality of your personal health information. All patient information will be kept secure and confidential, in compliance with applicable federal and state laws, including HIPAA.

### Changes to Terms

We reserve the right to modify these terms and conditions at any time. Changes take effect with the updated document posted on our website. Your continued use of our services constitutes your acceptance of the updated terms.

### Contact Us

If you have any questions or concerns about this Medical Consent or the services we provide, please contact us at OlsenMD@medicationandweightloss.com

Feel free to let me know if you need any further adjustments or additional information!