Telemedicine Informed Consent

HCG (Human Chorionic Gonadotropin) – Weight Loss Support Program

1. Telemedicine Acknowledgment

I understand that WildBerryMD provides elective wellness and weight management services via telemedicine. My consultation, medical history review, and any prescription decisions will occur remotely through secure electronic communication.

I understand that WildBerryMD is not a primary care provider and does not replace my regular primary care physician, OB/GYN, or specialist. I agree to remain under the care of my primary medical provider for all other medical conditions.

2. Purpose of Treatment

I am requesting participation in a weight loss program that may include HCG (Human Chorionic Gonadotropin) in combination with calorie restriction, dietary modification, exercise, and lifestyle changes.

I understand

HCG is not FDA-approved for weight loss
Its use in weight management is considered off-label
Treatment decisions are made only after review of my medical history and eligibility
Baseline or follow-up laboratory testing may be required before or during treatment

3. No Guarantee of Results

I understand that:

Weight loss results vary between individuals
Success depends on my adherence to dietary, exercise, and dosing instructions
No specific outcome is guaranteed
Long-term weight management requires ongoing lifestyle commitment
Individual results vary.

4. Risks and Possible Side Effects

All medications and dietary programs carry potential risks.

Potential Serious Risks (Rare but Possible)

Allergic reactions (hives, swelling, difficulty breathing)
Blood clots
Severe dizziness
Hormonal disturbances

If I experience signs of a severe reaction, I will seek emergency medical care immediately.

Possible Side Effects

Headache (often diet-related)
Irritability or mood changes
Fluid retention
Injection site irritation
Breast tenderness
Blood sugar fluctuations during calorie restriction

5. Contraindications

HCG may not be appropriate in individuals with:

Hormone-sensitive cancers
Undiagnosed uterine bleeding
Ovarian cysts
Thyroid or adrenal disorders
Heart or kidney disease
Seizure disorders
History of blood clots
Active psychiatric instability
Substance abuse disorders

I certify that I have fully disclosed my medical history and current medications.

6. Pregnancy and Breastfeeding

I certify that I am not pregnant and not breastfeeding. If I become pregnant, I will discontinue treatment immediately and notify WildBerryMD.

Initials (Female Patients): _______

7. Medication Interactions

I agree to disclose all prescription medications, supplements, and over-the-counter products and to notify WildBerryMD of any medication changes. I will not obtain HCG from another provider while enrolled in this program.

8. Emergency Care

WildBerryMD does not provide emergency services. If I experience a medical emergency, I will call 911 or go to the nearest emergency room.

9. Payment and Refund Policy

All services are self-pay.
WildBerryMD does not bill insurance for this program.
Lab companies bill patients directly when applicable.
Payment is due at time of service.
Products and medications are non-refundable and non-returnable due to safety regulations.

10. Indemnification and Hold Harmless Agreement

To the fullest extent permitted by law, I agree to release, indemnify, defend, and hold harmless WildBerryMD, its owners, medical providers, employees, contractors, affiliates, and associated healthcare professionals from any and all claims, liabilities, damages, losses, or expenses arising out of or related to:

My participation in this elective weight loss program
My failure to disclose medical history or medication use
My failure to follow medical instructions or dietary recommendations
My decision to pursue off-label HCG treatment

This indemnification does not apply to acts of gross negligence or willful misconduct.

11. Voluntary Participation

I understand that:

I may discontinue the program at any time
I have had the opportunity to ask questions
All my questions have been answered to my satisfaction
I should not sign this form if I have unanswered questions

By signing below, I acknowledge that I understand the risks, benefits, limitations, and off-label status of HCG for weight loss.

"*" indicates required fields

Instagram

This field is for validation purposes and should be left unchanged.

This field is hidden when viewing the form

Consent Description

WILDBERRYMD
Telemedicine Informed Consent
HCG (Human Chorionic Gonadotropin) – Weight Loss Support Program

1. Telemedicine Acknowledgment
I understand that WildBerryMD provides elective wellness and weight management services via telemedicine. My consultation, medical history review, and any prescription decisions will occur remotely through secure electronic communication.
I understand that WildBerryMD is not a primary care provider and does not replace my regular primary care physician, OB/GYN, or specialist. I agree to remain under the care of my primary medical provider for all other medical conditions.

2. Purpose of Treatment
I am requesting participation in a weight loss program that may include HCG (Human Chorionic Gonadotropin) in combination with calorie restriction, dietary modification, exercise, and lifestyle changes.
I understand:
• HCG is not FDA-approved for weight loss
• Its use in weight management is considered off-label
• Treatment decisions are made only after review of my medical history and eligibility
• Baseline or follow-up laboratory testing may be required

3. No Guarantee of Results
I understand that:
• Weight loss results vary between individuals
• Success depends on my adherence to dietary, exercise, and dosing instructions
• No specific outcome is guaranteed
• Long-term weight management requires ongoing lifestyle commitment
Individual results vary.

4. Risks and Possible Side Effects
All medications and dietary programs carry potential risks.
Potential Serious Risks (Rare but Possible)
• Allergic reactions (hives, swelling, difficulty breathing)
• Blood clots
• Severe dizziness
• Hormonal disturbances
If I experience signs of a severe reaction, I will seek emergency medical care immediately.

Possible Side Effects
• Headache (often diet-related)
• Irritability or mood changes
• Fluid retention
• Injection site irritation
• Breast tenderness
• Blood sugar fluctuations during calorie restriction

5. Contraindications
HCG may not be appropriate in individuals with:
• Hormone-sensitive cancers
• Undiagnosed uterine bleeding
• Ovarian cysts
• Thyroid or adrenal disorders
• Heart or kidney disease
• Seizure disorders
• History of blood clots
• Active psychiatric instability
• Substance abuse disorders
I certify that I have fully disclosed my medical history and current medications.

6. Pregnancy and Breastfeeding
I certify that I am not pregnant and not breastfeeding. If I become pregnant, I will discontinue treatment immediately and notify WildBerryMD.

Initials (Female Patients): _______

7. Medication Interactions
I agree to disclose all prescription medications, supplements, and over-the-counter products and to notify WildBerryMD of any medication changes. I will not obtain HCG from another provider while enrolled in this program.

8. Emergency Care
WildBerryMD does not provide emergency services. If I experience a medical emergency, I will call 911 or go to the nearest emergency room.

9. Payment and Refund Policy
• All services are self-pay.
• WildBerryMD does not bill insurance for this program.
• Lab companies bill patients directly when applicable.
• Payment is due at time of service.
• Products and medications are non-refundable and non-returnable due to safety regulations.

10. Indemnification and Hold Harmless Agreement
To the fullest extent permitted by law, I agree to release, indemnify, defend, and hold harmless WildBerryMD, its owners, medical providers, employees, contractors, affiliates, and associated healthcare professionals from any and all claims, liabilities, damages, losses, or expenses arising out of or related to:
• My participation in this elective weight loss program
• My failure to disclose medical history or medication use
• My failure to follow medical instructions or dietary recommendations
• My decision to pursue off-label HCG treatment
This indemnification does not apply to acts of gross negligence or willful misconduct.

11. Voluntary Participation
I understand that:
• I may discontinue the program at any time
• I have had the opportunity to ask questions
• All my questions have been answered to my satisfaction
• I should not sign this form if I have unanswered questions
By signing below, I acknowledge that I understand the risks, benefits, limitations, and off-label status of HCG for weight loss.

Patient Name*

Email*

Date of Birth*

Date*

Patient Signature*

CAPTCHA