Rules For Use Of Anti-Obesity Control Medications

NOTE: SIGNING THIS FORM DOES NOT GUARANTEE THAT YOUR PROVIDER(S) ATBWMedMD WILL FIND YOU TO BE AN APPROPRIATE CANDIDATE FOR ANTI-OBESITYMEDICATIONS, BUT ONLY THAT YOU HAVE READ, UNDERSTOOD, AND AGREE TO THETERMS OF MEDICATION USAGE SHOULD YOU AND DR. O. AKINRULI DECIDE UPONTHEIR USAGE NOW OR IN THE FUTURE.

Many anti-obesity medications are considered “controlled medications.” By law, a controlled medication can only be prescribed from one facility at a time; therefore I agree that only Dr.Omowunmi Akinruli will prescribe anti-obesity medications for me.

I agree that it is my responsibility to inform my physician(s) at BWMedMD and any otherproviders from whom I receive treatment of all medications prescribed to me. I understand that the use of anti-obesity medications is contraindicated with certain medical histories,allergies, or other medication use.

I agree that I will be completely honest in disclosing this information and will notify myphysician(s) at BWMedMD of any changes to my medical history or medication usage. I understand that failure to do so can be dangerous to my health.

I agree to take the medication only as prescribed and directed by Dr. Omowunmi Akinruli. I understand that taking medications in any way other than as directed and prescribed could affect my health and be dangerous. I also understand that medications are typically considered after a trial of failed weight loss with only nutritional/behavior modifications. If I am deemed a candidate for the medication program at BWMedMD, I am aware that the lowest effective dosage will be tried prior to increasing dosages.

I understand that medication prescriptions can be filled at a pharmacy of my choice. I agree to use only one pharmacy at a time to fill any scheduled anti-obesity prescriptions, and I give my permission for BWMedMD to notify area pharmacies of the terms of this agreement.

I will not share, sell, or trade my medication with anyone. I understand that doing so is illegal and will result in my discharge from the care of BWMedMD.

I understand that the use of some of the anti-obesity medications beyond 12 weeks is considered “off label” or not initially approved by the U.S. Food and Drug Administration (FDA). I understand that my physician(s) at BWMedMD is experienced in the area of obesity medicine and will, at times, elect/choose to use the anti-obesity medication(s) for longer periods of time as deemed appropriate for my individual treatment.

I understand that I am to report any side effects or adverse reactions of my medications to the physician(s) at BWMedMD.

I understand that it is my responsibility to follow the instructions carefully and that the purpose of this treatment is to assist me in my desire to decrease my body weight for improvement of health and to maintain weight loss. I understand that the purpose of medications for weight loss is to be used as an adjunct to a program that includes nutrition and/or physical activity and/or behavior modification.

I agree that my physician(s) at BWMedMD may sometimes taper and/or stop my medication to evaluate its effect on my weight loss and/or hunger and health.

I understand that much of the success of the program will depend on my efforts and that there are NO GUARANTEES in medical treatment in the disease of obesity. I also understand that I will have to continue monitoring my weight after active weight loss.