Disclaimer
By signing this consent form, you understand and agree to give full consent to Fella Medical Group, P.A., a Florida professional medical corporation (“Fella Medical” or “Practice”) and any of its medical providers, to perform medical procedures, treatments, or services as deemed necessary by the medical professionals employed by Fella Medical.
You understand that Fella Medical Group, P.A., its employees, agents, and medical providers, may use and disclose your personal health information to carry out treatment, payment, or healthcare operations for your medical care.
Medication Consent
You understand that the medical procedures, treatments, or services performed by Fella Medical Group, P.A., and any of its providers may include compounded semaglutide injections. Compounded semaglutide is a human-based glucagon-like peptide-1 (GLP-1) receptor agonist that is given as a supplement to a low-calorie diet and increased physical activity for the long-term control of weight in adult patients whose initial body mass index (BMI) is considered outside of the healthy range.
Indemnification
You agree to indemnify and hold harmless Fella Medical Group, P.A., its employees, agents, and medical providers from and against any and all claims, damages, expenses, losses, or liabilities arising out of or in connection with the medical procedures, treatments, or services provided by Fella Medical, including the administration of compounded semaglutide injections.
You hereby consent to the medical procedures, treatments, or services to be performed by Fella Medical, and acknowledge that you have read and fully understand the terms of this consent form.
Acknowledgment
You are aware that you should not take compounded semaglutide injections if you have a personal or family history of medullary thyroid carcinoma (thyroid cancer) or Multiple Endocrine Neoplasia syndrome type 2. Additionally, if you are pregnant or plan to become pregnant while taking this medicine, you should not take compounded semaglutide injections. It is also important to note that if you are diabetic and/or taking any medications related to lowering your blood sugar levels without speaking with your endocrinologist, you should not take compounded semaglutide injections. Specifically, if you are prescribed insulin, the combination may increase your risk of hypoglycemia (low blood sugar) and dosage adjustments by your provider may be necessary. If you have a history of pancreatitis or are allergic to BPC-157, semaglutide, or any other GLP-1 agonist, you should not take compounded semaglutide injections. It is important to discuss any allergies or medical history with your doctor or pharmacist before using this medication.
You are required to follow the medical program as directed by the Fella Medical Group, P.A., its employees, agents, and medical providers. This includes following any recommended treatment plans, taking prescribed medications with due diligence, attending scheduled appointments, following a suggested diet, and complying with any other instructions provided to you.
You are aware that the Fella Medical Group, P.A., its employees, agents, and medical providers will be conducting asynchronous medical check-ins which can be made through text or email by default.
You are required to attend scheduled meetings and respond to any personnel of Fella Medical Group as soon as possible. Failure to do so may delay your medical care or treatment.
It is important to note that if you fail to follow the medical program as directed by Fella Medical Group, P.A., its employees, agents, and medical providers, the company will not be held liable for any adverse outcomes or consequences that may result. It is your responsibility to ensure that you follow the medical program as directed in order to receive the full benefits of the telehealth program.
You have the right to refuse any medical procedures, treatments, or services offered by Fella Medical Group, P.A., its employees, agents, and medical providers, and that such refusal may delay your medical care or treatment.