Consent for Weight Management Services

House of Grace Treatment Center offers medical support for weight management and eating-related concerns. Treatment may include medications such as GLP-1 medications, Vyvanse, Topamax, Phentermine, and other related medicines to support obesity treatment, binge eating disorder, and long-term weight maintenance.

By signing this form, you agree to take part in our weight management program under the conditions below.

Eligibility

To receive weight management services, you must:

• Be at least 18 years old

• Have a BMI of 30 or higher, a BMI of 27 or higher with a related health condition (such as diabetes, high blood pressure, or sleep apnea) or binge eating disorder

• Allow us to review your medical history, current medications, and health information before any medication is prescribed

• Agree to attend follow-up visits so we can monitor your progress and adjust your plan if needed

Purpose of Treatment

Weight management treatment is designed to help with:

• Reducing appetite and cravings

• Increasing feelings of fullness

• Supporting blood sugar balance

• Supporting long-term lifestyle changes

Medication is only one part of care and may be combined with nutrition guidance, movement, and behavior changes.

Nature of Treatment

• Medications are prescribed individually based on your needs

• Some medications may be injections that you give yourself at home

• You will receive education on how to use your medication safely

Your Responsibilities

By joining this program, you agree to:

• Follow your treatment plan as prescribed

• Use medications exactly as instructed

• Attend scheduled follow-up visits

• Report side effects, concerns, or changes in health

• Provide honest and complete health information

• Tell us right away if anything about your health changes

Privacy and Medical Information

• Your medical and personal information will be kept private

• Information is used only for your care, safety, and quality improvement

• No identifying information will be shared without your permission, unless required by law

You also give permission for House of Grace Treatment Center to contact your other healthcare providers if needed to support safe treatment.

Voluntary Participation

• Taking part in weight management services is your choice

• You may stop at any time

• You will not be punished for choosing to leave the program

Emergencies

If you have severe side effects, allergic reactions, chest pain, trouble breathing, or feel unsafe:

• Call 911 or go to the nearest emergency room

• Then contact House of Grace Treatment Center as soon as you are safe

Communication

By enrolling, you agree that we may contact you by phone, text, email, or mail to:

• Share appointment reminders

• Give medication updates

• Support your care

You can opt out of non-essential messages at any time.

Medication Safety

You agree to:

• Check your medication when you receive it

• Store it safely and away from children

• Use only the medication prescribed to you

• Not share your medication with anyone else

If anything looks wrong with your medication, do not use it—contact us right away.

Payments and Appointments

• Payment is required before medication is dispensed

• Missed appointments may delay treatment and may result in a late cancellation or no-show fee

• Please give at least 24 hours’ notice to cancel or reschedule

Ending Services

House of Grace Treatment Center may pause or stop services if:

• Treatment becomes unsafe

• Instructions are not followed

• Information provided is false

• Appointments are repeatedly missed

• Payments are not made

You will be notified if this happens.