Blue Mountain Weightloss LLC Telemed consent

Prior to my treatment, I have fully disclosed any medical conditions or diseases. If I fail todisclose any medical condition that I have, I release the medical provider and Blue Mountain Weightloss LLC (BMW) from any liability associated with this procedure. I agree to immediatelyreport any problems that might occur to my medical provider during the treatment program. Ifurther understand that not complying with the dosage recommendations and dietary restrictionscould increase risks. If I do not follow these recommendations and restrictions, I agree torelease the medical provider and Blue Mountain Weightloss LLC from any liability arising as aresult of this.

While adverse side effects or complications are not expected, in the event that an illness doesoccur, I understand that I need to contact Blue Mountain Weightloss LLC immediately. If Iexperience an emergency situation, I understand that I need to go to an emergency facility. Iunderstand that if there are any changes in my medical history or there are any changes in mymedications or any other changes relevant to this procedure, I will advise the medical providerat that time. Complete patient confidentiality will be maintained at all times. I understand that Ican be successful without the use of appetite suppressants or injections as long as I amfollowing a reduced calorie nutrition plan and increasing my activity level, however the use ofsuch medications and injections may significantly help with my weight loss progress. Iunderstand that there is no guarantee that this program will work for me. I understand that Imust follow the program as directed in order to achieve weight loss. By consenting totreatment, I agree to pay, in full, for all visits and charges incurred at each visit. I understand thatthese charges are not covered by my insurance and Blue Mountain Weightloss LLC does notprovide or fill out claim forms for insurance purposes. I have read and fully understand theabove terms. All my questions have been addressed to my satisfaction. I agree to release themedical provider and Top Notch Vitality from any liability associated with this treatment.

Regarding GLP-1s(Semaglutide and Tirzepatide): I understand my medical provider and Blue Mountain Weightloss LLC is recommending a prescription for the medication Semaglutide orTirzepatide to facilitate and promote weight loss. Serious side effects of taking these drugs mayinclude: prolonged vomiting, inflammation of your pancreas (pancreatitis), changes in vision, lowblood sugar (hypoglycemia), kidney problems, and serious allergic reactions. Common sideeffects may include nausea, vomiting, diarrhea, stomach pain, constipation and possible ileus. Iagree to report any adverse reaction, side effect, or problem that might be related to GLP-1s. Iunderstand that I will be in charge of administering the prescribed drug and will conform with therecommended dosages and methods of administration provided by the medical provider and Blue Mountain Weightloss LLC. The drug provided to me is a compounded drug provided by astate licensed pharmacy. Compounding pharmacies are regulated and monitored for qualitypurposes by the state. The Food and Drug Administration permits its use, but the FDA does notreview these drugs to evaluate their safety, effectiveness, or quality. I understand and havebeen advised that I should not receive GLP-1s if I have a history of angioedema, anaphylaxis orother serious hypersensitivity reaction to GLP-1s or if I am pregnant or breastfeeding. GLP-1sare contraindicated in patients with a personal or family history of certain types of thyroidcancer, specifically thyroid C-cell tumors such as medullary thyroid carcinoma (MTC) or inpatients with multiple endocrine neoplasia syndrome type 2 (MEN 2). It is also contraindicated inpatients with type 1 diabetes and history of pancreatitis. I understand, in studies, somelaboratory animals given GLP-1s developed thyroid tumors, but it is not known if this medicationincreases the risk of tumors in humans GLP-1s should be used cautiously for people on otherblood sugar lowering medications and you should limit the amount of alcohol intake while on thismedication. By clicking the box, I acknowledge that I am not presently suffering from any of theabove conditions. I certify that I have read this form and that I understand its contents. I havebeen given the opportunity to ask questions about my condition, the medication to be used andthe risks and side effects involved, as well as alternative treatments. I have sufficient informationto give this informed consent. I understand I am required to pay in full at time of order and thatthe medication is non-refundable and non-returnable.

These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any diseases.