Title: Informed Consent for Telemedicine Weight Loss Program (GLP-1 Therapy)
Please read the following consent form carefully. By agreeing, you indicate that you understand and accept the medical treatment plan and its implications.
1. Voluntary Participation: I hereby voluntarily consent to participate in the weight loss program offered by PFC Club India Pvt. Ltd., which includes medical evaluation via telemedicine, prescription of a GLP-1 receptor agonist medication (e.g. Mounjaro/tirzepatide or a similar drug), and ongoing monitoring and support. I understand that the program will involve remote consultations with a licensed physician and that a personalized treatment plan will be developed for me.
2. Medicine Modality: I consent to the use of telemedicine for consultations and follow-ups. This means I will communicate with the doctor via electronic audio/video/text communications instead of in-person meetings. The procedure, benefits, and limitations of telemedicine have been explained to me (see Telemedicine Disclosure below). I acknowledge that I have the right to withdraw consent for telemedicine consultations at any time and request an in-person consultation instead (though in-person services are not directly provided by this online service, the doctor may advise me to see a local physician if needed).
3. Disclosure of Medical Information: I agree to accurately disclose my relevant health information to the healthcare providers. This includes my medical history, current symptoms, current medications and supplements, allergies, and lifestyle information as requested. I understand that the success and safety of the treatment depend on truthful and complete disclosure of this information. I have had the opportunity to discuss my medical history with the doctor and have disclosed any conditions such as thyroid disorders, pancreatitis history, gallbladder issues, eating disorders, or any other significant medical conditions. I also confirm that I am not pregnant and do not plan to become pregnant in the immediate future (or I have informed the doctor if I am or plan to be, and understand the medication is contraindicated in pregnancy).
4. Understanding of Treatment (GLP-1 Medication): The doctor has explained to me (through written information and/or discussion) the nature of the proposed medication therapy. I understand that the prescribed medication is a GLP-1 receptor agonist (for example, tirzepatide branded as Mounjaro) intended to assist with weight loss by regulating appetite and blood sugar. This medication is to be taken as an injection [frequency as directed, e.g. once weekly], and the dosage may be adjusted over time. I understand that this medication is approved for use in India and is a prescription-only drug. The doctor has informed me about how to use the medication, including proper injection technique, dosing schedule, and storage of the medication.
5. Alternative Treatments: The doctor has informed me about reasonable alternatives to this medication and program. These alternatives include lifestyle modification without medication, other medications (such as other anti-obesity drugs or appetite suppressants), or other interventions like surgical options in appropriate cases. I understand that I am free to decline the medication and pursue alternative treatments, and my consent here is specifically for the GLP-1 medication approach among the options.
6. Potential Benefits: I have been told that the potential benefits of this treatment include weight loss and improvement in weight-related health conditions (for example, better control of blood sugar levels, improved blood pressure, improvement in metabolic health markers, etc.). However, I understand that results are not guaranteed. I understand that achieving weight loss also requires my attention to dietary recommendations and exercise, and that the medication is an aid, not a standalone cure. No guarantee or assurance has been made as to how much weight I will lose or how quickly, and I understand results will vary for each individual.
7. Potential Risks and Side Effects: I acknowledge that the doctor has explained the possible risks and side effects associated with the GLP-1 medication and the program (see Acknowledgment of Risks and Side Effects below for details). I understand the common side effects (such as gastrointestinal effects like nausea or vomiting) and rare but serious risks (such as pancreatitis or allergic reactions). I have had the opportunity to ask questions about these risks and all my questions have been answered to my satisfaction. I acknowledge these risks and still consent to proceed with treatment.
8. No Guarantee and Patient Responsibility: I understand that no medical treatment is guaranteed to be effective. I agree to take responsibility for following the medical advice and instructions I am given. This includes administering the medication as prescribed, following the diet and exercise plan to the best of my ability, attending scheduled follow-up consultations (or rescheduling in a timely manner if I cannot attend), and reporting any problems or side effects promptly to the healthcare team. I will not deviate from the prescribed dosage on my own, and I will not combine the medication with any other weight loss treatments or drugs without consulting the program's doctor. I also agree not to take any other prescription weight loss medications or diabetes medications unless I have informed the doctor and received approval, due to the risk of drug interactions.
9. Follow-Up and Monitoring: I understand that this consent for treatment includes initial and periodic follow-up consultations. I commit to participating in the follow-up schedule the doctor recommends (e.g., monthly check-ins or as advised). During follow-ups, I will discuss my progress, any side effects, and any concerns so that the doctor can assess the safety and efficacy of the treatment for me. I acknowledge that the continuation of the medication will depend on these assessments (for instance, if I experience adverse effects or minimal benefit, the doctor might modify or discontinue the medication). I also consent to any routine tests the doctor deems necessary to monitor my health during the program (for example, blood tests for blood sugar, kidney function, etc., though such tests would be done through external labs with my separate consent).
10. Confidentiality: I understand that my identity and medical information will be kept confidential. The details of my consultations and treatment will not be released to anyone outside the service's medical and pharmacy team without my permission, except as required by law. I consent to my data being used within the service by those who need to know it for providing care (as per the Privacy Policy). Telemedicine consultations may be recorded for quality and record-keeping; I consent to such recording, knowing it will be stored securely and confidentially.
11. Right to Withdraw: I understand that my participation is voluntary and I can choose to withdraw from the weight loss program at any time. If I decide to discontinue the treatment or the program, I will inform the healthcare provider. I understand that if I withdraw, I should consult a doctor about safely stopping the medication (tapering if necessary) and that sudden discontinuation may cause certain effects (like return of appetite or other symptoms). I also understand that fees paid may be subject to the refund policy as stated in the Terms of Use (i.e., I may not get a refund for services or medication already provided).
12. Questions and Contact: I confirm that I have been given the opportunity to ask any questions regarding the treatment, telemedicine process, or this consent form. All such questions have been answered in a satisfactory manner. If I have questions later, I know I can contact the program's medical team or the support contact provided. I have also been provided with a way to contact or support staff in the event of any issues or emergencies related to the program (understanding that acute emergencies should go to ER as noted).
Consent Confirmation: By clicking "I Agree" (or signing below, if this were a physical form), I acknowledge that I have read and understood the information above. I consent to the medical treatment and telehealth services under the described conditions. I understand the risks and benefits, and I agree to comply with the instructions for safe use of the medication. This consent is valid for the duration of my participation in the program, unless I revoke it in writing.