ZYP Medical, LLC

Risks and Benefits Acknowledgement for Medical Weight Loss

I recognize the potential risks of this treatment program, and I also understand the potential benefits of weight loss, which may include:
1. Decreased risk of heart attack.
2. Decreased risk of adult-onset diabetes mellitus.
3. Decrease risk of developing arthritis and/or developing musculoskeletal conditions that are caused by excessive weight.
4. Increased emotional and psychological well-being.
5. Decreased risk of developing certain types of cancer.

I acknowledge that the medically managed weight loss program recommended to me by Joshua Peterson, ARNP and ZYP Medical, LLC is just one of multiple strategies to reduce weight. Alternative treatment options include:
1. Diet and exercise alone without medications.
2. The use of other kinds of medications to achieve appetite suppression.
3. Non-medical weight loss programs like Weight Watchers (for example).
4. Bariatric Surgery.

By checking the designated box on your intake form, I am consenting and I certify:

• That I 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, I am consenting THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.