HcG (human chorionic gonadotropin) is a prescription medication in a weight loss program that utilizes the protocol first created by Dr. A.T. Simeons. This protocol includes using the hormone in conjunction with a very specific, restrictive diet.
I understand that clinical results may vary depending on individual factors including but not limited to medical history, patient compliance with the weight loss program, and individual response to treatment.
I am aware of the following risks which include but are not limited to:
Allergic Reaction- With any drug there is the possibility of an allergic reaction or unusual reaction that may cause skin rash, difficulty breathing, collapse, or even death.
Gallbladder Attack- HcG is virtually free of negative side effects, but because you must follow a very low calorie, low fat diet, it can sometimes trigger a gallbladder attack in individuals who are genetically predisposed to gallbladder disease
Dehydration- Dehydration is possible if you are not following the protocol of ingesting approximately 2 liters of water daily.
Light Headedness/Faintness- If this occurs, you are likely not ingesting enough water.
Lethargy- As the body breaks down fat, you may feel tired. Make sure you are drinking the requisite amount of water, and if you are not taking a potassium sparing medication (e.g., some high blood pressure medications), you may take over the counter potassium supplement to help combat this symptom. You should check with your regular doctor to see if an over the counter potassium is contraindicated by medications you may be taking.
Your HcG medication should be discontinued if there is a severe adverse reaction.
I understand that the program and medications may involve risk. I understand that there is no weight loss guarantee or that I will be satisfied with my results. I further understand and acknowledge that there are no refunds, returns or store credit for the HcG program, even if I am required to discontinue using the program for any reason.
I have read and understand the information given to me about the HcG medication. I have asked and answered any questions that I may have after reading this form. I understand the possible side-effects and agree to notify my practitioner should they occur.
I understand that I may quit the program at any time. I agree to stop the HCG if I become pregnant and agree to advise my practitioner should I decide to become pregnant. No adverse side effects or complications are expected, but in the event that an illness does occur, I understand that I need to contact my practitioner and agree to do so. If I experience an emergency situation, I understand that I need to go to an emergency facility and to contact my practitioner as soon as possible.
I understand that photographs will be taken and used to monitor my results. The photographs may be used for educational purposes, lectures, publications, and advertisements. Confidentiality will be maintained.
I certify that I have read this entire informed consent and that I understand and agree to the information provided in this form. I agree to have my photograph taken to document my condition. My practitioner has explained the nature of my condition, the nature of the procedure, alternative treatments, and the benefits to be reasonably expected compared with alternative approaches. I have been given the opportunity to ask questions. This document is a written confirmation of these discussions. I agree that this consent supersedes any previous verbal or written disclosures. This consent is valid for all of my HcG weight loss programs in the future as well.
BY SIGNING BELOW, I ACKNOWLEDGE AND CERTIFY THAT I, _________________ HAVE READ AND UNDERSTAND THE “CONSENT, RELEASE AND INDEMNITY AGREEMENT” FOR THIS PROCEDURE, AND THAT I AM SIGNING IT VOLUNTARILY.
PLEASE SIGN YOUR FULL NAME BELOW IF YOU AGREE
Treatment Provider Signature
Medical Director Signature/ Nurse Practitioner Signature