House of Grace Treatment Center offers medical support for weight management and eating-related concerns. Treatment may include lifestyle counseling, nutrition guidance, behavioral support, and prescription medications such as GLP-1 medications, phentermine, topiramate (Topamax), Vyvanse, and other related medications to support obesity treatment, binge eating disorder, and long-term weight maintenance.

By signing this consent, I agree to participate in the House of Grace Medical Weight Management Program under the terms below.

Eligibility

To participate, I confirm that I:

• Am 18 years of age or older

• Meet one or more of the following:

  • BMI of 30 or higher

  • BMI of 27 or higher with a related medical condition (e.g., diabetes, high blood pressure, sleep apnea)

  • Diagnosis or symptoms consistent with binge eating disorder

• Allow review of my medical history, medications, labs, and health information

• Agree to attend follow-up visits for monitoring and safety

Purpose of Treatment

Weight management care may help with:

• Reducing appetite and cravings

• Increasing feelings of fullness

• Supporting blood sugar balance

• Supporting long-term lifestyle and behavior changes

I understand medication is one part of care and may be combined with nutrition, movement, and behavioral changes.

Nature of Treatment

• Medications are prescribed individually based on my needs

• Some medications may be self-administered injections

• I will receive education on safe use and storage

• No results or weight loss outcomes are guaranteed

My Responsibilities

I agree to:

• Follow my treatment plan as prescribed

• Take medications exactly as instructed

• Attend scheduled follow-up visits

• Report side effects or health changes promptly

• Provide honest and complete medical information

Voluntary Participation

• Participation is my choice

• I may stop treatment at any time

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

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 & Appointments

• Payment is required prior to medication dispensing

• Missed appointments may delay care and may result in fees

• At least 24 hours’ notice is required to cancel or reschedule

Termination of Services

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

• Treatment becomes unsafe

• Instructions are not followed

• Information provided is false or incomplete

• Appointments or payments are repeatedly missed

I consent to medical weight loss treatment that may include GLP-1 receptor agonists or related medications.

How GLP-1 Medications Work

GLP-1 medications help with weight management by:

• Reducing appetite

• Increasing fullness

• Slowing digestion

• Supporting blood sugar regulation

Possible Side Effects

Common side effects may include:

• Nausea, vomiting

• Diarrhea or constipation

• Abdominal discomfort

• Fatigue

• Decreased appetite

Rare but serious risks may include:

• Pancreatitis

• Gallbladder disease

• Kidney injury

• Low blood sugar (especially in diabetes)

• Thyroid tumors observed in animal studies

I agree to report concerning symptoms promptly.

Contraindications & Patient Disclosure

I confirm that I:

• Do NOT have a personal or family history of:

  • Medullary thyroid carcinoma (MTC)

  • Multiple Endocrine Neoplasia Type 2 (MEN2)

• Am not pregnant, breastfeeding, or trying to become pregnant

Compounded Medication Disclosure

I understand that some prescribed medications may be compounded, meaning:

• They are prepared by licensed compounding pharmacies

• They are not FDA-approved in the same way as brand-name medications

• They may differ in appearance, formulation, or dosing

I consent to the use of compounded medications when deemed medically appropriate.

Injection Training Acknowledgment

I acknowledge that I:

• Have received instruction on injection technique

• Understand storage and disposal

• Am responsible for administering medication correctly

Alternatives & No Guarantees

Alternatives include lifestyle changes, other medications, bariatric surgery, or no treatment. I understand that results are not guaranteed.

I consent to a psychiatric and behavioral health evaluation to assess conditions such as binge eating disorder, ADHD, mood disorders, anxiety, or other conditions that may impact weight, eating behaviors, or daily functioning. This evaluation may be requested by my provider as part of treatment planning, including when considering the prescription of controlled substances.

Scope of Evaluation and Treatment

I understand that this evaluation and ongoing treatment may include:

• Review of my medical and psychiatric history

• Assessment of eating behaviors, appetite patterns, and mental health symptoms

• Review of current medications and substance use history

• Use of diagnostic screening tools

• Discussion of treatment options, which may include:

  • Psychiatric medications

  • Behavioral or psychotherapy interventions focused on eating behaviors, cravings, motivation, and emotional regulation

  • Combined medication and therapy approaches when appropriate

I understand that therapy may be recommended to help address behavioral, emotional, and psychological factors that influence eating, weight, and treatment adherence.

Therapy as Part of Treatment

I understand that therapy related to weight management may focus on:

• Reducing binge eating or loss-of-control eating

• Addressing emotional or stress-related eating

• Improving awareness of hunger, fullness, and body cues

• Building coping skills for cravings, stress, and triggers

• Supporting sustainable behavior change rather than short-term dieting

Therapy may be provided alone or alongside medication, depending on my needs.

Controlled Substances

I understand that:

• Some treatments may include controlled substances (such as Vyvanse or phentermine)

• These medications require careful monitoring

• Prescriptions are based on medical necessity, safety, and clinical judgment

• Not all patients are appropriate candidates for controlled substances

I agree:

• Not to share, misuse, or sell prescribed medications

• To use medications exactly as prescribed

• To inform my provider of all medications, supplements, and substance use

• That lost or stolen prescriptions may not be replaced

Risks

I understand that possible risks of psychiatric medications and/or therapy may include:

• Increased heart rate or blood pressure

• Sleep disturbance

• Anxiety or mood changes

• Emotional discomfort during therapy

• Risk of dependency or misuse with certain medications

I understand that benefits, risks, and alternatives will be reviewed with me before starting or changing treatment.

Voluntary Participation

I understand that participation in psychiatric and behavioral health treatment, including therapy, is voluntary and that I may stop treatment at any time.

By checking the box, signing electronically, or continuing to use telehealth services provided by House of Grace Treatment Center, you acknowledge that you have read, understand, and agree to this Consent to Telehealth. You understand that your electronic agreement constitutes a legal signature and an ongoing agreement to these terms.

This consent applies to all telehealth services now and in the future unless withdrawn in writing.

1. Definition of Telehealth

Telehealth (also referred to as telemedicine) involves the delivery of healthcare services using electronic communications, information technology, or other digital means between a healthcare provider and a patient who are not in the same physical location.

Telehealth services may be used for:

• Medical and psychiatric evaluations

• Diagnosis and treatment planning

• Medication management and follow-up care

• Health education and counseling

Telehealth services may include, but are not limited to:

• Secure video visits

• Telephone visits

• Electronic messaging or portals

• Electronic transmission of medical records, photographs, questionnaires, laboratory results, and other health information

• Review of data from medical devices or patient-reported outcomes

2. Technology & Security

House of Grace Treatment Center uses electronic systems that incorporate network and software security protocols designed to protect the privacy and security of your health information. These systems include safeguards to help maintain data integrity and protect against intentional or unintentional disclosure.

Despite reasonable efforts to protect your information, you understand that:

• No system can guarantee absolute security

• Technology failures, interruptions, or unauthorized access may occur

3. Potential Benefits of Telehealth

Possible benefits include:

• Improved access to medical and psychiatric care

• Reduced travel time and scheduling barriers

• Ability to receive care in a familiar or convenient setting

• More timely follow-up and continuity of care

4. Potential Risks and Limitations of Telehealth

You understand that telehealth has limitations and potential risks, including but not limited to:

• Incomplete or inaccurate information provided electronically may affect medical decision-making

• The provider’s inability to perform certain physical exams, vital sign measurements, or in-person assessments

• Delays in evaluation or treatment due to technical failures

• The possibility that your condition may not be appropriate for telehealth care

• The possibility of a breach of privacy despite security safeguards

• Regulatory or licensing restrictions that may limit certain treatment options, including prescriptions

You understand that your provider may determine, at their discretion, that telehealth is not appropriate for your condition and may recommend in-person care or referral elsewhere.

5. Telehealth Is Not for Emergencies

You understand and agree that:

• Telehealth services are not intended for medical or psychiatric emergencies

• If you experience chest pain, trouble breathing, suicidal thoughts, severe allergic reactions, or feel unsafe, you must:

  • Call 911, or

  • Go to the nearest emergency room

House of Grace Treatment Center does not provide emergency services.

6. Patient Location & Licensing Requirements

You understand that:

• You must be physically located in a state where your provider is licensed at the time of the telehealth visit

• You are responsible for accurately reporting your location during each visit

• Providing incorrect location information may result in termination of the visit or inability to provide care

7. Confidentiality & HIPAA

You understand that:

• Telehealth services are subject to the same confidentiality and privacy protections as in-person healthcare services

• Your health information is protected under HIPAA and applicable state and federal laws

• Your information may be shared for treatment, payment, and healthcare operations as permitted by law

8. Access to Medical Records

You understand that:

• You have the right to access your medical records and telehealth-related health information as permitted by law

• Records created during telehealth visits become part of your medical record

9. Prescribing Limitations

You understand that:

• Certain medications, including controlled substances, may have additional legal or regulatory requirements when prescribed via telehealth

• Not all medications can be prescribed through telehealth

• Your provider will determine what treatments are medically appropriate and legally permitted

10. Voluntary Participation & Withdrawal of Consent

You understand that:

• Participation in telehealth services is voluntary

• You may withhold or withdraw consent at any time by notifying House of Grace Treatment Center

• Withdrawal of consent may limit your ability to continue care via telehealth

• Unless withdrawn, this consent is considered renewed with each telehealth visit

11. Acknowledgment & Consent

By signing below, checking the acknowledgment box, or continuing to use telehealth services, you confirm that:

• You have read and understand this Consent to Telehealth

• You understand the risks, benefits, and limitations of telehealth

• You had the opportunity to ask questions

• You voluntarily consent to receive healthcare services via telehealth