PHENTERMINE INFORMED CONSENT

I request the use of Phentermine, along with strict dietary restrictions for the purpose of weight loss. I understand that as part of the program. I will be given a limited physical; I will be instructed on how to administer Phentermine myself.  

Prior to taking Phentermine, I have fully disclosed any medical conditions or diseases such as a history of gallbladder disease, diabetes, autoimmune disease, HIV, heart disease, liver disease, kidney disease, uncontrolled high blood pressure, seizure disorders, blood disorder (anemia, thalassemia, hemophilia etc.) emphysema or asthma, and any history of stroke or cancer. These contraindications have been fully discussed with me. Further contraindications are outlined below.  If I fail to disclose any medical condition that I have, I release Echelon Integrative Health, LLC and their medical physicians and facility from any liability associated with this treatment initials: _______

Do not use Phentermine if you have used an MAO inhibitor such as furazolidone (Furoxone), isocarboxazid (Marplan), phenelzine (Nardil), rasagiline Azilect), selegiline (Eldepryl, Emsam, Zelapar), or tranylcypromine (Parnate) 14 days prior. SSRI, SNRI, mood stabilizers or antidepressants. A dangerous drug interaction could occur, leading to serious side effects. Do not take it if you're pregnant or breastfeeding. Avoid monster drinks, ADHD meds (Adderall)

Side Effects:
While phentermine is generally free of negative side effects, there is the possibility of the following:

• Dry mouth            Diarrhea    Nausea/Vomiting    Panic attacks
• Unpleasant taste        Constipation    Fatigue        Heartburn
• Stomach Pain            Hypertension    Skin Rash or itching    Lactic acidosis
• Insomnia or Restlessness    Heart attack    Anger            Stroke

I understand Phentermine treatments may involve these risks and other unknown risks: Initials _____

I consent solely to arbitration as a legal means of settlement.