I ______________________________________ authorize
Dr. George C. Stege III, Family Care Group of Kentuckiana P.S.C. and whomever
they designate as their assistants, to help me in my weight reduction
efforts. I understand that my program
may consist of a balanced deficit diet, a regular exercise program, instruction
in behavior modification techniques, and may involve the use of appetite
suppressant medications. Other treatment options may include a very low calorie
diet, or a protein supplemented diet. I further understand that if appetite suppressants
are used, they may be used for durations exceeding those recommended in the
medication package insert. It has been explained to me that these medications
have been used safely and successfully in private medical practices as well as
in academic centers for periods exceeding those recommended in the product
literature.
I understand that any medical treatment may involve
risks as well as the proposed benefits. I also understand that there are
certain health risks associated with remaining overweight or obese. Risks of
this program may include but are not limited to nervousness, sleeplessness,
headaches, dry mouth, gastrointestinal disturbances, weakness, tiredness,
psychological problems, high blood pressure, rapid heartbeat, and heart
irregularities. These and other possible risks could, on occasion, be serious
or even fatal. Risks associated with
remaining overweight are tendencies to high blood pressure, diabetes, heart
attack and heart disease, arthritis of the joints including hips, knees, feet
and back, sleep apnea, and sudden death. I understand that these risks may be
modest if I am not significantly overweight, but will increase with additional
weight gain.
I understand that much of the success of the program
will depend on my efforts and that there are no guarantees or assurances that
the program will be successful. I also understand that obesity may be a
chronic, life-long condition that may require changes in eating habits and
permanent changes in behavior to be treated successfully.
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
to me. My questions have been answered to my complete satisfaction. I have been
urged and have been given all the time I need to read and understand this form.
If you have any questions regarding the risks or
hazards of the proposed treatment, or any questions whatsoever concerning the
proposed treatment or other possible treatments, ask your doctor now before
signing this consent form.
Date: Time:
Witness: Patient:
(Or person with authority to
consent for patient)