Please complete the form below.
Your Current BMI is {calculation-1}
CAUTION or AVOID phentermine.
CAUTION or AVOID phentermine and Monitor BP daily
AVOID phentermine
AVOID SEMAGLUTIDE
AVOID WEIGHT LOSS PROGRAM
CAUTION with phentermine & SEMAGLUTIDE
AVOID phentermine, CAUTION with SEMAGLUTIDE
CAUTION with phentermine or SEMAGLUTIDE
AVOID with phentermine
CAUTION with phentermine
CAUTION with HCG & AVOID SEMAGLUTIDE
CAUTION with HCG or SEMAGLUTIDE
CAUTION with SEMAGLUTIDE
CAUTION with HCG
AVOID Bupropion-Wellbutrin
Avoid Phentermine
If Seizure disorder is selected, AVOID Bupropion-Wellbutrin
If Cancer is selected, CAUTION with HCG & AVOID SEMAGLUTIDE
HCG DIET Commitments you must make: Commit to HCG diet strictly - NO DEVIATIONS. You will most likely experience little or no hunger after the first 3 days. It is important in the first 2 days of the diet that you eat some of the foods you will miss. After the first 2 days, you will comfortably consume a strict 500-900 calorie diet. Birth control pills, antibiotics, and other prescribed medications are allowed on the HCG diet. You must accept that any deviation from your 500-1,000 calorie diet will likely lead to weight gain. You must accept the rare possibility of low blood sugar which may manifest as lightheadedness, weakness or trembling, or sweating that is typically relieved by a snack like almonds which you are expected to keep on hand. You must continue the 500-900 calorie diet THREE days after stopping HCG use. You agree to not consume any sugars, carbohydrates, and fats including (rice, bread, potatoes, pastries, etc) for 3 weeks after stopping the use of HCG. I agree to follow the HCG Diet strictly. I understand my success is not guaranteed. I personally accept the rare possibility of side effects including, but not limited to fainting, low blood sugar, gall bladder attacks, or gout arthritis attacks. I agree to not hold anyone involved in my care responsible for any lack of success, unpleasant event, or side effects.
Weight Loss: Informed Consent I understand that my recommended weight loss treatments including prescription medications and non-FDA approved HCG or off-label use of prescription medications, lipo injections, and supplements are generally considered safe and beneficial to the majority of patients; however, Wyoming Integrative Medicine and Pharmacy LLC, Kentuckiana Integrative Medicine, Kentuckiana Medicine, and affiliated companies, it’s employees, clinicians, physicians, pharmaceutical providers, compound pharmacy providers cannot guarantee effectiveness and cannot guarantee that NO negative or adverse or harmful events will NOT occur to patients. This agreement will remain in force until canceled in writing by the patient. FEMALES, it is your responsibility to obtain a mammogram or thermogram, transvaginal ultrasound, and pelvic /pap smear from your doctor before starting HCG treatment. HCG is NOT FDA-approved for weight loss. BENEFITS with weight loss treatments and therapy MAY include improved appearance and energy, improved heart function, musculoskeletal health, psychological function, and sexual function; however, with all medical treatments, there are some rare but potential risks including but not limited to allergic reactions, cancer, and even death. Wyoming Medicine and Pharmacy LLC, Kentuckiana Medicine, and its clinicians will NOT act or assume the role of being the patient’s primary care physician. Patients receiving treatment must accept all known risks as well as future unknown risks including but not limited to allergic reactions, aggravation-worsening of the presenting problems, aggravation-worsening of other conditions, cancer, passing out from low blood sugar, gouty arthritis attacks, gall bladder attacks, heart attack, stroke, blood clots even death. Clearly, the clinicians at Wyoming Integrative Medicine and Pharmacy LLC and Kentuckiana Medicine and affiliated companies believe that the benefits far outweigh the risks. European studies show that the benefits of weight control with phentermine outweigh the risks since weight control MAY help avoid diabetes, cancer, and heart disease. The patient has read numerous articles on website and elsewhere and believes that treatment benefits outweigh the risks that he/she is willing to accept all known and unknown associated risks. All of the patient’s questions regarding the following treatments: both on-label and off-label use of Phenteramine [Adipex], Phendimetrazine, Diethylpropion, Metformin, Off Label Non-FDA approved HCG, SEMAGLUTIDE alone and Compounded “Off Label Semaglutide with B6 & BPC157” have been completely answered to his or her satisfaction and the patient elects to proceed with treatment. PATIENT UNDERSTANDS THAT ALL WEIGHT LOSS MEDICATIONS and weight loss supplements MUST STOP IF BECOMES PREGNANT. Especially Phentermine which is known to cause BIRTH DEFECTS.
I agree and understand that by choosing to receive treatment at this office with “Off Label” medications, vitamins, supplement treatments, Injections, and IV therapy that are unapproved by FDA, I am voluntarily joining a PMMA – PRIVATE MEDICAL MEMBERSHIP ASSOCIATION; therefore, I agree to keep track of my treatment and expenses and to NOT request medical records or expense records. Furthermore, I forbid this clinic from releasing my records to any other clinic, lawyer, insurance company, or anyone requesting information. Only, I the patient will have the authority to share my medical information and payment history. I understand my receipt on the day of service is my record of payment and received treatment.
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Article 1: IC 34-57-2-1-22 Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by Indiana law, and not by a lawsuit or resort to court process except as Indiana law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. You are giving up your right to jury or court trial. Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or service provided by the physicians, clinicians, or employees including any spouse, heirs, friends, colleagues other relatives or any other parties connected to the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician’s partners, associates, association, corporation or partnership, and the employees, agents, and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party’s own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law. Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator. The parties’ consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of Indiana law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to, Uniform Arbitration Act Indiana Code IC 34-57-2 -1 through- IC 34-57-2 -22 Any party may bring before the arbitrators a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Uniform Arbitration Act Indiana Code IC 34-57-2 -1 through- IC 34-57-2 -22 however, depositions may be taken without prior approval of the neutral arbitrator.
Article 4: General Provisions: All claims based upon the same incident, transaction, or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable Indiana statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the Uniform Arbitration Act Indiana Code IC 34-57-2 -1 through- IC 34-57-2 -22
Article 5: It is the intent of this agreement to apply to all medical services rendered at any time for any condition. Article 6: I understand that I have the right to receive a copy of this arbitration agreement. I have read and understand all of the above information. If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE WILL BE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. Liability Waiver: On behalf of myself, my heirs, and assigns, to the fullest extent permitted by law, I hereby release and forever discharge, and agree not to sue and to indemnify and hold harmless Wyoming Integrative Medicine and Pharmacy LLC, Kentuckiana Integrative Medicine, and affiliated companies, physicians, clinicians, and their employees, agents, representatives, and volunteers from and against any and all known and unknown liabilities, risks, accidents, and responsibilities for any claims against any of them by reason of any injury to person or property, or death, which occurs as a direct or indirect consequence of any of the offered and or received treatments including, but not limited to the use of hormone replacement, weight loss medications, Injections, IV therapies and or supplements. I voluntarily assume all responsibility and risk of loss, damage, illness, and/or injury to my person or property, which is due to any of the above-listed treatments, medications, and or other supplements. I fully realize that by so doing I am eliminating my rights to be compensated by the above-mentioned persons/companies for injury due to use of medications, IV Therapy, hormones, and or supplements. I have been well informed of the associated medical risks and voluntarily assume and accept them. By signing this document, you are informing everyone that you understand all of this document, that you have been given plenty of time to read it, that all your questions have been answered to your satisfaction, and that you consent to treatment. Finally, you will not challenge the validity of this agreement under any circumstances.
HCG DIET Commitments you must make: Commit to HCG diet strictly - no deviations. You will most likely experience little or no hunger after the first 3 days. It is important in the first 2 days of the diet that you eat some of the foods you will miss. After the first 2 days, you will comfortably consume a strict 500-900 calorie diet. Birth control pills, antibiotics, and other prescribed medications are allowed on the HCG diet. You must accept that any deviation from your 500-1,000 calorie diet will likely lead to weight gain. You must accept the rare possibility of low blood sugar which may manifest as lightheadedness, weakness or trembling or sweating that is typically relieved by a snack like almonds which you are expected to keep on hand. You must continue the 500-900 calorie diet THREE days after stopping HCG use. You agree to not consume any sugars, carbohydrates, and fats including (rice, bread, potatoes, pastries, etc) for 3 weeks after stopping use of HCG. I agree to follow the HCG Diet strictly. I understand my success is not guaranteed. I personally accept the rare possibility of side effects including, but not limited to fainting, low blood sugar, gall bladder attacks, or gout arthritis attacks. I agree to not hold anyone involved in my care responsible for any lack of success, unpleasant event, or side effects.
Weight Loss
Informed Consent I understand that my recommended weight loss treatments including prescription medications and non-FDA approved HCG or off-label use of prescription medications, lipo injections, and supplements are generally considered safe and beneficial to the majority of patients; however, Wyoming Medicine and Pharmacy LLC, Kentuckiana Medicine, and affiliated companies, it’s employees, clinicians, physicians, pharmaceutical providers, compound pharmacy providers cannot guarantee effectiveness and cannot guarantee that NO negative or adverse or harmful events will NOT occur to patients. This agreement will remain in force until canceled in writing by the patient. FEMALES, it is your responsibility to obtain a mammogram or thermogram, transvaginal ultrasound, and pelvic /pap smear from your doctor before starting HCG treatment. HCG is NOT FDA-approved for weight loss. BENEFITS with weight loss treatments and therapy may include improved appearance and energy, improved heart function, musculoskeletal health, psychological function, and sexual function; however, with all medical treatments, there are some rare but potential risks including but not limited to allergic reactions, cancer, and even death. Wyoming Medicine and Pharmacy LLC, Kentuckiana Medicine, and its clinicians will NOT act or assume the role of being the patient’s primary care physician. Patients receiving treatment must accept all known risks as well as future unknown risks including but not limited to allergic reactions, aggravation-worsening of the presenting problems, aggravation-worsening of other conditions, cancer, passing out from low blood sugar, gouty arthritis attacks, gall bladder attacks, heart attack, stroke, blood clots even death. Clearly, the clinicians at Wyoming Integrative Medicine and Pharmacy LLC and Kentuckiana Medicine and affiliated companies believe that the benefits far outweigh the risks. European studies show that the benefits of weight control with phentermine outweigh the risks since weight control may help avoid diabetes, heart disease, and cancer. The patient has read numerous articles on website and elsewhere and believes that treatment benefits outweigh the risks that he/she is willing to accept. All of the patient’s questions regarding the following treatments: both on-label and off-label use of Phentermine [Adipex], Phendimetrazine, Diethylpropion, Metformin, Off Label Non-FDA approved HCG, SEMAGLUTIDE alone and Compounded “Off Label Semaglutide with B6 & BPC157” have been completely answered to his or her satisfaction and the patient elects to proceed with treatment. PATIENT UNDERSTANDS THAT ALL WEIGHT LOSS MEDICATIONS and weight loss supplements MUST STOP IF BECOME PREGNANT. Especially Phentermine which is known to cause BIRTH DEFECTS. I agree and understand that by receiving treatment at this office I am joining a PMMA – PRIVATE MEDICAL MEMBERSHIP ASSOCIATION; therefore, I agree to keep track of my treatment and expenses and to NOT request medical records or expense records. I have read and understand all of the above information and agree to accept all Known and Unknown risks.
Physician – Patient Arbitration Agreement and Informed Consent for Treatment ____________________________________________
Article 1: IC 34-57-2-1-22 Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by Indiana law, and not by a lawsuit or resort to court process except as Indiana law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. You are giving up your right to jury or court trial. Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or service provided by the physicians, clinicians, or employees including any spouse, heirs, friends, colleagues other relatives or any other parties connected to the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician’s partners, associates, association, corporation or partnership, and the employees, agents, and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party’s own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law. Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder, any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of Indiana law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to, Uniform Arbitration Act Indiana Code IC 34-57-2 -1 through- IC 34-57-2 -22 Any party may bring before the arbitrators a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Uniform Arbitration Act Indiana Code IC 34-57-2 -1 through- IC 34-57-2 -22 however, depositions may be taken without prior approval of the neutral arbitrator. Article 4: General Provisions: All claims based upon the same incident, transaction, or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable Indiana statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the Uniform Arbitration Act Indiana Code IC 34-57-2 -1 through- IC 34-57-2 -22
Article 5: It is the intent of this agreement to apply to all medical services rendered any time for any condition. Article 6: I understand that I have the right to receive a copy of this arbitration agreement. I have read and understand all of the above information. If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE WILL BE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. Liability Waiver: On behalf of myself, my heirs, and assigns, to the fullest extent permitted by law, I hereby release and forever discharge, and agree not to sue and to indemnify and hold harmless Wyoming Integrative Medicine and Pharmacy LLC, Kentuckiana Integrative Medicine and affiliated companies, physicians, clinicians, and their employees, agents, representatives, and volunteers from and against any and all known and unknown liabilities, risks, accidents, and responsibilities for any claims against any of them by reason of any injury to person or property, or death, which occurs as a direct consequence of the use of hormone replacement and or weight loss medications and or supplements. I voluntarily assume all responsibility and risk of loss, damage, illness, and/or injury to my person or property, which is due to any of the above-listed treatments, medications, and or other supplements. I fully realize that by so doing I am eliminating my rights to be compensated by the above-mentioned persons/companies for injury due to use of hormones and or supplements. I have been well informed of the associated medical risks and voluntarily assume and accept them. By signing this document, you are informing everyone that you understand all of this document, that you have been given plenty of time to read it, that all your questions have been answered to your satisfaction, and that you consent to treatment. Finally, you will not challenge the validity of this agreement under any circumstances.
Patient Informed Consent for Weight Loss Program and Appetite Suppressants
I hereby authorize Dr. Rafael Cruz, and whomever he designates as his assistants, to provide medical care for me to assist me in my weight reduction efforts, to achieve the goals of weight loss and weight maintenance. I understand that such care may include but is not limited to physical examination, laboratory screening, EKG testing, instruction in behavior modification techniques, nutritional counseling, fitness counseling, vitamin supplementation, and may involve the use of appetite suppressants.
I have read and understand my doctor’s statements that follow: “Medications, including appetite suppressants, have labeling worked out between the makers of the medication and the Food and Drug Administration. This labeling contains, among other things, suggestions for using the medication. The appetite suppressant labeling suggestions are generally based on shorter-term studies (up to 12 weeks) using the dosages indicated in the labeling.”
“As a physician, I have found the appetite suppressants helpful for periods in excess of 12 weeks, and at times in larger doses than those suggested in the labeling. I am not required to use the medication as the labeling suggests, but I do use the labeling as a source of information along with my own experience, the experience of my colleagues, and recent studies. Such usage has not been as systematically studied as that suggested in the labeling and it is possible, as with most other medications, that there could be serious side effects.”
“The more common side effects of the appetite suppressants include nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, psychological problems, medication allergies, high blood pressure, rapid heartbeat, and heart irregularities. Less common, but more serious, risks are primary pulmonary hypertension and heart valve disease, heart attack, stroke, and death.
Physical injury can result from such things as increased exercise and activity, and GI side effects, such as constipation, diarrhea, and/or bloating, or development of gallbladder disease, can occur from rapid weight loss. These and other possible risks could, on occasion, be serious or fatal resulting in death. You must decide if you are willing to accept these risks of side effects, even if they might be serious, for the possible help the appetite suppressants may give you.”
By signing this consent, you are agreeing to accept all known and unknown risks associated with the use of HCG or supplements or medications like phentermine, that you are aware of the contraindications and risks involved with taking HCG and Cancer. In the unlikely event that you currently have an existing breast or female cervical cancer; it is possible that HCG may stimulate an already existing cancer even though HCG has NOT been proven to cause cancer. HCG is the pregnancy hormone and is extremely elevated in pregnancy and does not seem to cause cancer. It is your responsibility to obtain a Mammogram Thermagram, Transvaginal Ultrasound and a cervical PAP Smear under the care of your personal physician. If you elect to ignore our recommendation and do not obtain these tests, you do so at your own risk and release and forever discharge Wyoming Integrative Medicine and Pharmacy LLC, Kentuckiana Integrative Medicine, Kentuckiana Weight Loss, all affiliated companies, personnel, its employees, agents of any responsibility should you be harmed or die directly or indirectly from using prescribed supplements or medications or HCG.
Patient’s Consent: I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained, or any questions I have concerning them have not been answered to my complete satisfaction. I have been urged to take all the time I need in reading and understanding this form and in talking with my doctor regarding risks associated with the proposed treatment and regarding other treatments not involving the appetite suppressants.
I agree and understand that by receiving treatment at this office I am joining a PMMA – PRIVATE MEDICAL MEMBERSHIP ASSOCIATION; therefore, I agree to keep track of my treatment and expenses and to NOT request medical records or expense records. I have read and understand all of the above information and agree to accept all Known and Unknown risks.
WARNING: IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THE PROPOSED TREATMENT, OR ANY QUESTIONS WHATSOEVER CONCERNING THE PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK YOUR DOCTOR BEFORE SIGNING THIS CONSENT FORM.
Important: After submitting your medical intake form you will need to call 812-913-4416 to schedule your appointment. For insurance services please wait 3 days before you call so we can verify your benefits and find out if your insurance covers our services.
