EAST ZONE MEDICO LEGAL SERVICES PVT LTD Informed Consent and General Contract for Participation in the New Moms Program 1. I hereby consent to participate in the Medical University of South Carolina Weight Management Center’s New Moms Program. The initial duration of the program is 4 weeks with the option to extend for a longer time. I understand that this program will describe and recommend changes that may help me to lose excess pounds and manage my weight more successfully. 2. I understand that to participate in this program I must be between 2 weeks and 12 months postpartum. Weigh at least 10 pounds more than I did prior to my pregnancy and have a body mass index of at least 20. 3. I understand the Weight Management Center will not be monitoring my vital signs (blood pressure, pulse and respiratory rate) or drawing blood for any laboratory values and is in no way responsible for my medical care. I am still under the care of my primary care physician and agree to remain under the care of a primary care physician during my participation in this weight loss program. 4. I understand that before I can begin the program I must provide written clearance from my physician for my participation. I will provide the Center staff with contact information if I wish them to send the clearance form to my physician. I am also encouraged to have the most recent laboratory values faxed or mailed from my primary car physician or gynecologist to the Weight Management Center for review prior to entering the program. 5. I understand that as a part of this program, I will be encouraged to increase my level of physical activity and begin a regular exercise program. I am aware that I should not start an exercise program until my doctor has given me written clearance to exercise by completing the Physician’s Release Form mentioned above and I have given that clearance to the Weight Management Center. 6. I am advised that no guarantee can be made concerning the expected results of this program. I understand that my chances of successful weight loss depend to a large extent on how well I follow through with the dietary, exercise, and other changes that are recommended, and on my attendance at meetings. 7. I understand that supplemental products (i.e. bars and pudding/shakes) provided at the Weight Management Center, similar to all commercially prepared food products, may contain ingredients (including but not limited to nuts and milk products) that produce an allergic reaction in some individuals. I also understand that it is my responsibility not to consume products that I have a known allergy to and also that the Weight Management Center cannot be held responsible for any emergent allergic conditions. 8. I realize that if I am diagnosed with an illness that requires medical treatment or postpartum depression I may be advised to discontinue or interrupt the program. 9. I understand that my nutritional needs will be greater if I am nursing, and I agree to keep the Center Dietitian advised of my nursing status. I also understand that I should not follow a weight loss program if I become pregnant again, as it is unadvisable and potentially risky to the fetus for a pregnant woman to follow a weight loss diet. If I suspect that I have become pregnant, I will immediately notify the program staff and immediately return to a more calorically adequate eating plan. 10. I understand that information collected during this program may be published and that I will not be identified. The information will be combined with that from other participants. My identity will never be revealed in any publication or presentation about this work. 11. Staff at the Weight Management Center may contact me at times over the next fifteen years to request information concerning my weight status, related factors, and the kinds of information I provided while participating in the program. My participation in the clinical program is not dependent on my consenting to this section. 12. A refund for prepaid but unreceived services will be granted only if I terminate for medical reasons or because of moving out of the Charleston-Trident area. A $35.00 processing charge will be deducted from all refunds regardless of reason for refund. No fees for services I have received will be refunded under any circumstances. I have read and understand this form. I have had an adequate chance to ask questions. Date: ________________ Patient’s Signature: ________________________ Witness’s Signature: _______________________
Posted on: Sun, 16 Mar 2014 11:59:40 +0000
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