Terms and Conditions

GENERAL PATIENT CONSENT FOR WEIGHT LOSS THERAPY

Peak Medical Wellness

This document confirms my informed consent to receive medical evaluation and management services from Peak Medical Wellness.

1. Scope of Services

Peak Medical Wellness provides medical evaluation and management services related to weight loss and weight management. Treatment plans are determined by the treating clinician based on individualized medical necessity, clinical judgment, and patient-specific factors. Treatment goals may include weight reduction, weight maintenance, and improvement of obesity-related health conditions.

I understand that Peak Medical Wellness does not serve as my primary care provider (PCP), and I agree to continue routine and preventive care with my designated PCP.

2. Payment & Insurance

Services are due at the time of service unless otherwise specified.
Health insurance typically does not cover services provided by Peak Medical Wellness.
Upon request, itemized invoices may be provided for possible insurance reimbursement.
Services may be tax-deductible as a medical expense; I understand I should consult a tax professional.

All services and products rendered are non-refundable. Medications cannot be returned once dispensed, in accordance with state and federal regulations.

3. Prescription Issuance

Scheduling an appointment does not guarantee that a prescription will be issued. Each prescribing decision is made solely at the discretion of the treating clinician based on clinical appropriateness.

4. Medication Management & Patient Responsibilities

I agree to:

Take medications exactly as prescribed
Not distribute or share prescriptions or injection supplies
Disclose all medications, supplements, allergies, and relevant medical history
Notify my provider of any changes in my health status

I understand that improper or unsupervised use of prescribed medications may result in harm.

5. Adverse Effects & Medical Emergencies

If I experience side effects or unexpected symptoms, I agree to promptly contact my provider. In urgent or emergent situations, I will seek care from an urgent care center or emergency department or call 911.

6. Follow-Up & Compliance

I understand the importance of follow-up appointments for safe and effective treatment. The provider may determine whether laboratory testing is medically necessary and may review prior results at their discretion.

7. Late / Missed Appointments

Late arrivals or missed appointments may result in a $50 fee. This policy is subject to change.

8. Minors

For telemedicine visits involving minors, parental or legal guardian consent is required, and a parent/guardian may be asked to participate in part of the visit.

9. Termination of Care

Peak Medical Wellness reserves the right to discontinue the provider-patient relationship if clinically or ethically necessary, including for non-compliance or missed follow-up. Reasonable efforts will be made to ensure continuity of care through referrals or patient-selected providers.

10. Voluntary Consent

I voluntarily request treatment from Peak Medical Wellness. I have had the opportunity to ask questions, and all questions have been answered to my satisfaction.

GLP-1 / COMPOUNDED MEDICATION INFORMED CONSENT ADDENDUM

(Applies when GLP-1 or other weight-management medications are prescribed)

This addendum supplements the General Patient Consent.

1. Medication Overview

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs), including semaglutide or tirzepatide, may be prescribed as part of a comprehensive weight-management plan that includes nutrition and lifestyle modification.

2. Compounded Medications

I acknowledge that:

Prescriptions may be sourced from a licensed compounding pharmacy
Compounded medications are not FDA-approved
They are prepared pursuant to patient-specific prescriptions
Depending on the pharmacy’s regulatory classification, the facility may be registered with and inspected by the U.S. Food and Drug Administration

I understand that compounded medications cannot be directly compared to FDA-approved commercial drugs in terms of safety, efficacy, or consistency.

3. Pharmacy Coordination

Prescriptions issued by Peak Medical Wellness are coordinated through pharmacies selected by the provider based on clinical, safety, availability, and logistical considerations. I understand that I may choose to seek care or prescriptions elsewhere at any time.

4. Contraindications

I understand I should not take GLP-1 medications if I have:

A history of pancreatitis
Personal or family history of medullary thyroid carcinoma (MTC)
Multiple Endocrine Neoplasia type 2 (MEN2)
Pregnancy or plans to become pregnant
Known hypersensitivity to GLP-1 receptor agonists

This list is not exhaustive.

5. Possible Side Effects

Common side effects may include:

Nausea, vomiting, diarrhea, constipation
Abdominal discomfort, bloating, reflux
Headache, dizziness, fatigue

Rare but serious adverse effects may occur, including life-threatening complications. I understand to seek immediate medical care for severe symptoms.

6. Serious Warnings

Animal studies have shown an increased risk of thyroid C-cell tumors with GLP-1 receptor agonists. It is unknown whether this risk applies to humans. I agree to notify my provider of symptoms such as neck mass, hoarseness, or difficulty swallowing.

7. Medication Use & Storage