ZYP Medical, LLC

Regaining Weight Acknowledgement

There is a risk of regaining the weight you have lost. Obesity is a chronic condition, and the majority of overweight individuals who lose weight have a tendency to regain all or some of it back over time. Factors which favor maintaining weight loss include exercise, adherence to a healthy diet (low-calorie, nutritious, and full of lean proteins and vegetables), and planning a strategy for coping with weight regain before it occurs. Successful treatment may take months or even years. Utilizing medications to assist you in your weight loss goals in addition to diet and exercise could result in the weight coming back if you do not maintain eating a healthy diet and exercising. Additionally, if you have had fluctuations in your weight in the past, it may be more difficult to maintain the weight you lose.

By checking the designated box on your intake form, you are signing your agreement that you understand that regaining weight after completing or discontinuing your treatment is possible and that ZYP Medical, LLC is not responsible for any weight that has been regained. You are acknowledging your understanding of the possibility of regaining the weight once your treatment has been discontinued.

You also agree and consent:

• That I certify that you have read or had this form explained/read to me and I understand its contents including the risks and benefits of telemedicine.

• That I have had the opportunity to ask questions and have had them answered to my satisfaction.

By checking the designated box, you are consenting THAT YOU HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.