New Patients

READY TO GET AHEAD?
FILL OUT THIS FORM BEFORE YOU COME

Please be aware that new patients will need to fill out some basic forms along with your medical history which will make your fist visit longer.  For your convenience we have posted these forms here so that you can speed up your fist visit.  

Please print and bring these completed forms to your first visit.

PATIENT BASIC INFORMATION

SEX

 

HOW DID YOU HEAR ABOUT US?

(please check all that apply)

 

EMERGENCY CONTACTS

 

FINANCIAL POLICY

Thank you for selecting Bee-Lite Medical Weight Loss-Evans, LLC for your health care. We are honored to be of service to you and
your family. This is to inform you of our billing requirements and our financial policy. Please be advised that payment for all
services will be due at the time services are rendered. For your convenience we accept Visa, MasterCard, American Express and
Cash.

 

HIPPA PRIVACY NOTICE

 

PATIENT INFORMED CONSENT FOR APPETITE SUPPRESSANTS

  1. I understand and acknowledge that treatment by Bee-Lite Medical Weight Loss, Dr. Julian Hutchins, Sr., MD and their designated assistants is limited solely to assistance with weight reduction efforts. This treatment does not provide a substitute or replacement for any regular physician. Bee-Lite Medical Weight Loss, LLC and Dr. Julian Hutchins, Sr., MD does not treat acute or chronic medical problems, and I agree to see my regular physician for these problems.
    1. I authorize Dr. Julian Hutchins, Sr., MD and whomever he designates as his assistants to assist me in my weight reduction efforts. I understand my treatment may involve but not be limited to, the use of appetite suppressants for more than 12 weeks and when indicated in higher doses than the dose indicated in the appetite suppressant labeling. I understand that my program may consist of a balanced deficit diet, a regular exercise program, and instructions in behavior modification techniques, and may involve the use of appetite suppressant medications.
    2. I have read and understand my doctor's statements that follow:
      “Medications, including the appetite suppressants, have labeling worked out between the makers of the medication and Food and Drug Administration. This labeling contains, among other things, suggestions for using the medication. The appetite suppressant labeling suggestions are generally based on shorter term studies (up to 12 weeks) using the dosages indicated in the labeling.”
      “As a physician, I have found the appetite suppressants helpful for periods far in excess of 12 weeks, and at times in larger doses than those suggested in the labeling. As a physician, I am not required to use the medication as the labeling suggests, but I do use the labeling as a source of information along with my own experience, the experience of my colleagues, recent longer term studies and recommendations of university based investigators. Based on these, I have chosen, when indicated, to use the appetite suppressants for longer periods of time and at times, in increased doses.”
      “Such usage has not been as systematically studied as that suggested in the labeling and it is possible, as with most other medications, that there could be serious side effects (as noted below).”
      “As a physician, I believe the probability of such side effects is outweighed by the benefit of the appetite suppressant use for longer periods of time and when indicated in increased doses. However, you must decide if you are willing to accept the risks of side effects, even if they might be serious, for the possible help the appetite suppressants use in this manner may give.”
    3. I understand it is my responsibility to follow the instructions carefully and to report to the doctor treating me for my weight any significant medical problems that I think may be related to my weight control program as soon as reasonably possible.
    4. I understand the purpose of this treatment is to assist me in my desire to decrease my body weight and maintain this weight loss. I understand my continuing to receive the appetite suppressant will be dependent on my progress in weight reduction and weight maintenance.
    5. I understand there are other ways and programs that can assist me in my desire to decrease my body weight and to maintain this weight loss.

    In particular, a balanced calorie counting program or an exchange eating program without the use of the appetite suppressant would likely prove successful if followed, even though I would probably be hungrier without the appetite suppressant.

    1. RISKS OF PROPOSED TREATMENT:
      I understand this authorization is given with the knowledge that the use of the appetite suppressants for more than twelve weeks and in higher doses than the dose indicated in the labeling involves some risks and hazards. The more common include: nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, psychological problems, medication allergies, high blood pressure, rapid heartbeat and heart irregularities. Less common, but more serious, risks are primary pulmonary hypertension and valvular heart disease. These and other possible risks could, on occasion, be serious or fatal.
    2. NO GUARANTEE:
      I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I also understand that I will have to continue watching my weight all my life if I am to be successful.
    3. PATIENT'S CONSENT:
      I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained, or any questions I have concerning them have not been answered to my complete satisfaction, I have been urged to take all the time I need in reading and understanding this form and in talking with my doctor regarding risks associated with the proposed treatment and regarding other treatments not involving the appetite suppressants. I also understand that participation in this program is strictly voluntary and is my choice to participate or not. I understand that I may discontinue this treatment at any time at my discretion.
    4. WARNING:
      IF YOU HAVE ANY QUESTION AS TO THE RISKS OR HAZARDS OF THE PROPOSED TREATMENT, OR ANY QUESTIONS WHATSOEVER CONCERNING THE PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK YOUR DOCTOR NOW BEFORE SIGNING THE CONSENT SIGNATURE FORM.
 
I have read and fully understand this consent form. I realize I should not sign this form if all items have not been explained to me. My questions have been answered to my complete satisfaction. I have been urged and have been given all the time I need to read and understand this form.
(If you have any questions regarding the risks or hazards of the proposed treatment, or any questions whatsoever concerning the proposed treatment or other possible treatments, ask your doctor now before signing this consent form.)

 

PATIENT MEDICAL HISTORY

Present Health Status:
  1. Are you in good health at the present time, to the best of your knowledge?

    If "No", explain:

     

  2. Are you under a doctor's care at the present time?

    If "Yes", explain:

     

  3. Are you taking any medications at the present time?

    Prescription Drugs (List all) (Check box to note if medication is Prescription or Over the Counter)
Name of MedicationPrescriptionOver the CounterDosageSchedule
  1. Any allergies to sulfa/sulfur type medications or any other medications?
MedicationReaction
Do you have any of the following:
  1. History of High Blood Pressure?

     

  2. History of Diabetes?


     

  3. History of Heart Attack or Chest Pain or other Heart condition?

    If "Yes", explain.

     

  4. History of Swelling Feet?

     

  5. History of Frequent:

    Medications for Headaches/Migraines:

     

  6. History of Constipation? (Difficulty in bowel movements)

     

  7. History of Glaucoma?

     

  8. History of Sleep Apnea?

    Do you use C-PAP?

     

  9. Any Surgery?

    Specify with date:


     

  10. Do you have any other medical problems or concerns?

 

PAST MEDICAL HISTORY

(CHECK ALL THAT APPLY)

 

FAMILY HISTORY

Please complete this section in its entirety.

Tell us of your family's medical history to the best of your ability including these items as they apply:

AgeGeneral HealthDiseasesOverweightCause of Death
Father
Mother
Brother(s)
Sister(s)
Has any blood relative ever had any of the following?

High Blood Pressure:

Kidney Disease:

Heart Attack/Stents/Bypass/Stroke:

At what age did they have their heart/stroke problems?

 

 

LIFESTYLE EVALUATION

  1. Do you drink coffee, soda, or tea?

     

  2. Do you wake up hungry during the night?

     

  3. Previous diets and/or weight loss medications you have tried: list description (or name) and your results:


     

  4. Do you drink alcohol?

    Daily?

    Weekly?

    Occasionally?

     

  5. Smoking Habits (choose only one)





 

CONSENT TO TREATMENT

(WOMEN ONLY)

I understand that Phentermine and other anorectic medications should NOT be taken during pregnancy, due to the chance of damage to the fetus. The medications have been explained to me fully and I am aware of the risks involved.
To the best of my knowledge, I am not pregnant. I am aware of the precautions that should be taken to avoid pregnancy while I am on the medication. If I become pregnant, I will advise both clinic and my OB/GYN immediately.

 

PHYSICIAN DECLARATION

I have explained the contents of this document to the patient and have answered all the patient's related questions, and to the best of my knowledge, I feel the patient has been adequately informed concerning the benefits and risks associated with the use of the appetite suppressants, the benefits and risks associated with the use of the appetite suppressants, the benefits and risks associated with alternative therapies and the risks of continuing in an overweight state. After being adequately informed, the patient has consented to therapy involving the appetite suppressants in the manner indicated above.

 

DISCLOSURE AND CONSENT FORM

TO THE PATIENT (AND OTHERS LEGALLY RESPONSIBLE FOR THE PATIENT): You have the right, as a patient, to be informed about your condition and how integrative and alternative medicine may be applied in a treatment plan. This disclosure is intended to provide an opportunity for you to make an informed decision so that you may give or withhold your consent to treatment that may be considered unconventional by physicians trained only in the United States. NOTICE: Refusal to consent to the integrative and alternative procedure(s) shall not affect your right to future care or treatment.

I voluntarily request that Dr. Julian Hutchins, Sr., MD and other affiliated health care personnel as he may deem necessary, treat my condition (or the condition of the person for whom I am responsible) as described below

I understand that some of, or all of, the following integrative and alternative treatments are planned for me (or the person for whom I am responsible), and I voluntarily consent and authorize the following: Administration of homeopathic remedies, herbal and nutritional therapies, off label use of pharmaceuticals, injectable vitamins and Amino Acids, B12 with or without Lipotropic, Choline, Methionine, Inositol, as well as:

I understand that no warranty or guarantee has been made regarding results of treatment. I realize that there may be risks and hazards related to the planned integrative treatment, including worsening of present symptoms, development of new symptoms (especially detox reactions) and undesirable interactions between various treatments, both conventional and alternative, as well as:

I have been given an opportunity to ask questions about the treatment of this health condition using conventional, integrative and alternative methods. I have had an opportunity to discuss the possible risks and hazards of treatment and non-treatment, and I believe that I have sufficient information to this informed consent. I certify this form has been fully explained to me, that I have read it (or have it read to me), that the blank spaces have been filled in, and that I understand its contents. I also certify that Dr. Julian Hutchins, Sr. MD has provided this Disclosure and Consent Form to me and fully explained the diagnostic and treatment options available and has made no guarantees to me as to the success of this treatment. I acknowledge that Dr. Julian Hutchins, Sr. MD, has informed me that he functions only as an educator and consultant not as the primary care physician for any patient. I have assured him that I have another primary physician and do not/will not rely on Dr. Julian Hutchins, Sr. MD for that role.

PATIENT BASIC INFORMATION

SEX

 

HOW DID YOU HEAR ABOUT US?

(please check all that apply)

 

EMERGENCY CONTACTS

 

FINANCIAL POLICY

Thank you for selecting Bee-Lite Medical Weight Loss-Evans, LLC for your health care. We are honored to be of service to you and
your family. This is to inform you of our billing requirements and our financial policy. Please be advised that payment for all
services will be due at the time services are rendered. For your convenience we accept Visa, MasterCard, American Express and
Cash.

 

HIPPA PRIVACY NOTICE

 

PATIENT INFORMED CONSENT FOR APPETITE SUPPRESSANTS

  1. I understand and acknowledge that treatment by Bee-Lite Medical Weight Loss, Dr. Julian Hutchins, Sr., MD and their designated assistants is limited solely to assistance with weight reduction efforts. This treatment does not provide a substitute or replacement for any regular physician. Bee-Lite Medical Weight Loss, LLC and Dr. Julian Hutchins, Sr., MD does not treat acute or chronic medical problems, and I agree to see my regular physician for these problems.
    1. I authorize Dr. Julian Hutchins, Sr., MD and whomever he designates as his assistants to assist me in my weight reduction efforts. I understand my treatment may involve but not be limited to, the use of appetite suppressants for more than 12 weeks and when indicated in higher doses than the dose indicated in the appetite suppressant labeling. I understand that my program may consist of a balanced deficit diet, a regular exercise program, and instructions in behavior modification techniques, and may involve the use of appetite suppressant medications.
    2. I have read and understand my doctor's statements that follow:
      “Medications, including the appetite suppressants, have labeling worked out between the makers of the medication and Food and Drug Administration. This labeling contains, among other things, suggestions for using the medication. The appetite suppressant labeling suggestions are generally based on shorter term studies (up to 12 weeks) using the dosages indicated in the labeling.”
      “As a physician, I have found the appetite suppressants helpful for periods far in excess of 12 weeks, and at times in larger doses than those suggested in the labeling. As a physician, I am not required to use the medication as the labeling suggests, but I do use the labeling as a source of information along with my own experience, the experience of my colleagues, recent longer term studies and recommendations of university based investigators. Based on these, I have chosen, when indicated, to use the appetite suppressants for longer periods of time and at times, in increased doses.”
      “Such usage has not been as systematically studied as that suggested in the labeling and it is possible, as with most other medications, that there could be serious side effects (as noted below).”
      “As a physician, I believe the probability of such side effects is outweighed by the benefit of the appetite suppressant use for longer periods of time and when indicated in increased doses. However, you must decide if you are willing to accept the risks of side effects, even if they might be serious, for the possible help the appetite suppressants use in this manner may give.”
    3. I understand it is my responsibility to follow the instructions carefully and to report to the doctor treating me for my weight any significant medical problems that I think may be related to my weight control program as soon as reasonably possible.
    4. I understand the purpose of this treatment is to assist me in my desire to decrease my body weight and maintain this weight loss. I understand my continuing to receive the appetite suppressant will be dependent on my progress in weight reduction and weight maintenance.
    5. I understand there are other ways and programs that can assist me in my desire to decrease my body weight and to maintain this weight loss.

    In particular, a balanced calorie counting program or an exchange eating program without the use of the appetite suppressant would likely prove successful if followed, even though I would probably be hungrier without the appetite suppressant.

    1. RISKS OF PROPOSED TREATMENT:
      I understand this authorization is given with the knowledge that the use of the appetite suppressants for more than twelve weeks and in higher doses than the dose indicated in the labeling involves some risks and hazards. The more common include: nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, psychological problems, medication allergies, high blood pressure, rapid heartbeat and heart irregularities. Less common, but more serious, risks are primary pulmonary hypertension and valvular heart disease. These and other possible risks could, on occasion, be serious or fatal.
    2. NO GUARANTEE:
      I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I also understand that I will have to continue watching my weight all my life if I am to be successful.
    3. PATIENT'S CONSENT:
      I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained, or any questions I have concerning them have not been answered to my complete satisfaction, I have been urged to take all the time I need in reading and understanding this form and in talking with my doctor regarding risks associated with the proposed treatment and regarding other treatments not involving the appetite suppressants. I also understand that participation in this program is strictly voluntary and is my choice to participate or not. I understand that I may discontinue this treatment at any time at my discretion.
    4. WARNING:
      IF YOU HAVE ANY QUESTION AS TO THE RISKS OR HAZARDS OF THE PROPOSED TREATMENT, OR ANY QUESTIONS WHATSOEVER CONCERNING THE PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK YOUR DOCTOR NOW BEFORE SIGNING THE CONSENT SIGNATURE FORM.
 
I have read and fully understand this consent form. I realize I should not sign this form if all items have not been explained to me. My questions have been answered to my complete satisfaction. I have been urged and have been given all the time I need to read and understand this form.
(If you have any questions regarding the risks or hazards of the proposed treatment, or any questions whatsoever concerning the proposed treatment or other possible treatments, ask your doctor now before signing this consent form.)

 

PATIENT MEDICAL HISTORY

Present Health Status:
  1. Are you in good health at the present time, to the best of your knowledge?

    If "No", explain:

     

  2. Are you under a doctor's care at the present time?

    If "Yes", explain:

     

  3. Are you taking any medications at the present time?

    Prescription Drugs (List all) (Check box to note if medication is Prescription or Over the Counter)
Name of MedicationPrescriptionOver the CounterDosageSchedule
  1. Any allergies to sulfa/sulfur type medications or any other medications?
MedicationReaction
Do you have any of the following:
  1. History of High Blood Pressure?

     

  2. History of Diabetes?


     

  3. History of Heart Attack or Chest Pain or other Heart condition?

    If "Yes", explain.

     

  4. History of Swelling Feet?

     

  5. History of Frequent:

    Medications for Headaches/Migraines:

     

  6. History of Constipation? (Difficulty in bowel movements)

     

  7. History of Glaucoma?

     

  8. History of Sleep Apnea?

    Do you use C-PAP?

     

  9. Any Surgery?

    Specify with date:


     

  10. Do you have any other medical problems or concerns?

 

PAST MEDICAL HISTORY

(CHECK ALL THAT APPLY)

 

FAMILY HISTORY

Please complete this section in its entirety.

Tell us of your family's medical history to the best of your ability including these items as they apply:

AgeGeneral HealthDiseasesOverweightCause of Death
Father
Mother
Brother(s)
Sister(s)
Has any blood relative ever had any of the following?

High Blood Pressure:

Kidney Disease:

Heart Attack/Stents/Bypass/Stroke:

At what age did they have their heart/stroke problems?

 

 

LIFESTYLE EVALUATION

  1. Do you drink coffee, soda, or tea?

     

  2. Do you wake up hungry during the night?

     

  3. Previous diets and/or weight loss medications you have tried: list description (or name) and your results:


     

  4. Do you drink alcohol?

    Daily?

    Weekly?

    Occasionally?

     

  5. Smoking Habits (choose only one)





 

CONSENT TO TREATMENT

(WOMEN ONLY)

I understand that Phentermine and other anorectic medications should NOT be taken during pregnancy, due to the chance of damage to the fetus. The medications have been explained to me fully and I am aware of the risks involved.
To the best of my knowledge, I am not pregnant. I am aware of the precautions that should be taken to avoid pregnancy while I am on the medication. If I become pregnant, I will advise both clinic and my OB/GYN immediately.

 

PHYSICIAN DECLARATION

I have explained the contents of this document to the patient and have answered all the patient's related questions, and to the best of my knowledge, I feel the patient has been adequately informed concerning the benefits and risks associated with the use of the appetite suppressants, the benefits and risks associated with the use of the appetite suppressants, the benefits and risks associated with alternative therapies and the risks of continuing in an overweight state. After being adequately informed, the patient has consented to therapy involving the appetite suppressants in the manner indicated above.

 

DISCLOSURE AND CONSENT FORM

TO THE PATIENT (AND OTHERS LEGALLY RESPONSIBLE FOR THE PATIENT): You have the right, as a patient, to be informed about your condition and how integrative and alternative medicine may be applied in a treatment plan. This disclosure is intended to provide an opportunity for you to make an informed decision so that you may give or withhold your consent to treatment that may be considered unconventional by physicians trained only in the United States. NOTICE: Refusal to consent to the integrative and alternative procedure(s) shall not affect your right to future care or treatment.

I voluntarily request that Dr. Julian Hutchins, Sr., MD and other affiliated health care personnel as he may deem necessary, treat my condition (or the condition of the person for whom I am responsible) as described below

I understand that some of, or all of, the following integrative and alternative treatments are planned for me (or the person for whom I am responsible), and I voluntarily consent and authorize the following: Administration of homeopathic remedies, herbal and nutritional therapies, off label use of pharmaceuticals, injectable vitamins and Amino Acids, B12 with or without Lipotropic, Choline, Methionine, Inositol, as well as:

I understand that no warranty or guarantee has been made regarding results of treatment. I realize that there may be risks and hazards related to the planned integrative treatment, including worsening of present symptoms, development of new symptoms (especially detox reactions) and undesirable interactions between various treatments, both conventional and alternative, as well as:

I have been given an opportunity to ask questions about the treatment of this health condition using conventional, integrative and alternative methods. I have had an opportunity to discuss the possible risks and hazards of treatment and non-treatment, and I believe that I have sufficient information to this informed consent. I certify this form has been fully explained to me, that I have read it (or have it read to me), that the blank spaces have been filled in, and that I understand its contents. I also certify that Dr. Julian Hutchins, Sr. MD has provided this Disclosure and Consent Form to me and fully explained the diagnostic and treatment options available and has made no guarantees to me as to the success of this treatment. I acknowledge that Dr. Julian Hutchins, Sr. MD, has informed me that he functions only as an educator and consultant not as the primary care physician for any patient. I have assured him that I have another primary physician and do not/will not rely on Dr. Julian Hutchins, Sr. MD for that role.

PATIENT BASIC INFORMATION

SEX

 

HOW DID YOU HEAR ABOUT US?

(please check all that apply)

 

EMERGENCY CONTACTS

 

FINANCIAL POLICY

Thank you for selecting Bee-Lite Medical Weight Loss-Evans, LLC for your health care. We are honored to be of service to you and
your family. This is to inform you of our billing requirements and our financial policy. Please be advised that payment for all
services will be due at the time services are rendered. For your convenience we accept Visa, MasterCard, American Express and
Cash.

 

HIPPA PRIVACY NOTICE

 

PATIENT INFORMED CONSENT FOR APPETITE SUPPRESSANTS

  1. I understand and acknowledge that treatment by Bee-Lite Medical Weight Loss, Dr. Julian Hutchins, Sr., MD and their designated assistants is limited solely to assistance with weight reduction efforts. This treatment does not provide a substitute or replacement for any regular physician. Bee-Lite Medical Weight Loss, LLC and Dr. Julian Hutchins, Sr., MD does not treat acute or chronic medical problems, and I agree to see my regular physician for these problems.
    1. I authorize Dr. Julian Hutchins, Sr., MD and whomever he designates as his assistants to assist me in my weight reduction efforts. I understand my treatment may involve but not be limited to, the use of appetite suppressants for more than 12 weeks and when indicated in higher doses than the dose indicated in the appetite suppressant labeling. I understand that my program may consist of a balanced deficit diet, a regular exercise program, and instructions in behavior modification techniques, and may involve the use of appetite suppressant medications.
    2. I have read and understand my doctor's statements that follow:
      “Medications, including the appetite suppressants, have labeling worked out between the makers of the medication and Food and Drug Administration. This labeling contains, among other things, suggestions for using the medication. The appetite suppressant labeling suggestions are generally based on shorter term studies (up to 12 weeks) using the dosages indicated in the labeling.”
      “As a physician, I have found the appetite suppressants helpful for periods far in excess of 12 weeks, and at times in larger doses than those suggested in the labeling. As a physician, I am not required to use the medication as the labeling suggests, but I do use the labeling as a source of information along with my own experience, the experience of my colleagues, recent longer term studies and recommendations of university based investigators. Based on these, I have chosen, when indicated, to use the appetite suppressants for longer periods of time and at times, in increased doses.”
      “Such usage has not been as systematically studied as that suggested in the labeling and it is possible, as with most other medications, that there could be serious side effects (as noted below).”
      “As a physician, I believe the probability of such side effects is outweighed by the benefit of the appetite suppressant use for longer periods of time and when indicated in increased doses. However, you must decide if you are willing to accept the risks of side effects, even if they might be serious, for the possible help the appetite suppressants use in this manner may give.”
    3. I understand it is my responsibility to follow the instructions carefully and to report to the doctor treating me for my weight any significant medical problems that I think may be related to my weight control program as soon as reasonably possible.
    4. I understand the purpose of this treatment is to assist me in my desire to decrease my body weight and maintain this weight loss. I understand my continuing to receive the appetite suppressant will be dependent on my progress in weight reduction and weight maintenance.
    5. I understand there are other ways and programs that can assist me in my desire to decrease my body weight and to maintain this weight loss.

    In particular, a balanced calorie counting program or an exchange eating program without the use of the appetite suppressant would likely prove successful if followed, even though I would probably be hungrier without the appetite suppressant.

    1. RISKS OF PROPOSED TREATMENT:
      I understand this authorization is given with the knowledge that the use of the appetite suppressants for more than twelve weeks and in higher doses than the dose indicated in the labeling involves some risks and hazards. The more common include: nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, psychological problems, medication allergies, high blood pressure, rapid heartbeat and heart irregularities. Less common, but more serious, risks are primary pulmonary hypertension and valvular heart disease. These and other possible risks could, on occasion, be serious or fatal.
    2. NO GUARANTEE:
      I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I also understand that I will have to continue watching my weight all my life if I am to be successful.
    3. PATIENT'S CONSENT:
      I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained, or any questions I have concerning them have not been answered to my complete satisfaction, I have been urged to take all the time I need in reading and understanding this form and in talking with my doctor regarding risks associated with the proposed treatment and regarding other treatments not involving the appetite suppressants. I also understand that participation in this program is strictly voluntary and is my choice to participate or not. I understand that I may discontinue this treatment at any time at my discretion.
    4. WARNING:
      IF YOU HAVE ANY QUESTION AS TO THE RISKS OR HAZARDS OF THE PROPOSED TREATMENT, OR ANY QUESTIONS WHATSOEVER CONCERNING THE PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK YOUR DOCTOR NOW BEFORE SIGNING THE CONSENT SIGNATURE FORM.
 
I have read and fully understand this consent form. I realize I should not sign this form if all items have not been explained to me. My questions have been answered to my complete satisfaction. I have been urged and have been given all the time I need to read and understand this form.
(If you have any questions regarding the risks or hazards of the proposed treatment, or any questions whatsoever concerning the proposed treatment or other possible treatments, ask your doctor now before signing this consent form.)

 

PATIENT MEDICAL HISTORY

Present Health Status:
  1. Are you in good health at the present time, to the best of your knowledge?

    If "No", explain:

     

  2. Are you under a doctor's care at the present time?

    If "Yes", explain:

     

  3. Are you taking any medications at the present time?

    Prescription Drugs (List all) (Check box to note if medication is Prescription or Over the Counter)
Name of MedicationPrescriptionOver the CounterDosageSchedule
  1. Any allergies to sulfa/sulfur type medications or any other medications?
MedicationReaction
Do you have any of the following:
  1. History of High Blood Pressure?

     

  2. History of Diabetes?


     

  3. History of Heart Attack or Chest Pain or other Heart condition?

    If "Yes", explain.

     

  4. History of Swelling Feet?

     

  5. History of Frequent:

    Medications for Headaches/Migraines:

     

  6. History of Constipation? (Difficulty in bowel movements)

     

  7. History of Glaucoma?

     

  8. History of Sleep Apnea?

    Do you use C-PAP?

     

  9. Any Surgery?

    Specify with date:


     

  10. Do you have any other medical problems or concerns?

 

PAST MEDICAL HISTORY

(CHECK ALL THAT APPLY)

 

FAMILY HISTORY

Please complete this section in its entirety.

Tell us of your family's medical history to the best of your ability including these items as they apply:

AgeGeneral HealthDiseasesOverweightCause of Death
Father
Mother
Brother(s)
Sister(s)
Has any blood relative ever had any of the following?

High Blood Pressure:

Kidney Disease:

Heart Attack/Stents/Bypass/Stroke:

At what age did they have their heart/stroke problems?

 

 

LIFESTYLE EVALUATION

  1. Do you drink coffee, soda, or tea?

     

  2. Do you wake up hungry during the night?

     

  3. Previous diets and/or weight loss medications you have tried: list description (or name) and your results:


     

  4. Do you drink alcohol?

    Daily?

    Weekly?

    Occasionally?

     

  5. Smoking Habits (choose only one)





 

CONSENT TO TREATMENT

(WOMEN ONLY)

I understand that Phentermine and other anorectic medications should NOT be taken during pregnancy, due to the chance of damage to the fetus. The medications have been explained to me fully and I am aware of the risks involved.
To the best of my knowledge, I am not pregnant. I am aware of the precautions that should be taken to avoid pregnancy while I am on the medication. If I become pregnant, I will advise both clinic and my OB/GYN immediately.

 

PHYSICIAN DECLARATION

I have explained the contents of this document to the patient and have answered all the patient's related questions, and to the best of my knowledge, I feel the patient has been adequately informed concerning the benefits and risks associated with the use of the appetite suppressants, the benefits and risks associated with the use of the appetite suppressants, the benefits and risks associated with alternative therapies and the risks of continuing in an overweight state. After being adequately informed, the patient has consented to therapy involving the appetite suppressants in the manner indicated above.

 

DISCLOSURE AND CONSENT FORM

TO THE PATIENT (AND OTHERS LEGALLY RESPONSIBLE FOR THE PATIENT): You have the right, as a patient, to be informed about your condition and how integrative and alternative medicine may be applied in a treatment plan. This disclosure is intended to provide an opportunity for you to make an informed decision so that you may give or withhold your consent to treatment that may be considered unconventional by physicians trained only in the United States. NOTICE: Refusal to consent to the integrative and alternative procedure(s) shall not affect your right to future care or treatment.

I voluntarily request that Dr. Julian Hutchins, Sr., MD and other affiliated health care personnel as he may deem necessary, treat my condition (or the condition of the person for whom I am responsible) as described below

I understand that some of, or all of, the following integrative and alternative treatments are planned for me (or the person for whom I am responsible), and I voluntarily consent and authorize the following: Administration of homeopathic remedies, herbal and nutritional therapies, off label use of pharmaceuticals, injectable vitamins and Amino Acids, B12 with or without Lipotropic, Choline, Methionine, Inositol, as well as:

I understand that no warranty or guarantee has been made regarding results of treatment. I realize that there may be risks and hazards related to the planned integrative treatment, including worsening of present symptoms, development of new symptoms (especially detox reactions) and undesirable interactions between various treatments, both conventional and alternative, as well as:

I have been given an opportunity to ask questions about the treatment of this health condition using conventional, integrative and alternative methods. I have had an opportunity to discuss the possible risks and hazards of treatment and non-treatment, and I believe that I have sufficient information to this informed consent. I certify this form has been fully explained to me, that I have read it (or have it read to me), that the blank spaces have been filled in, and that I understand its contents. I also certify that Dr. Julian Hutchins, Sr. MD has provided this Disclosure and Consent Form to me and fully explained the diagnostic and treatment options available and has made no guarantees to me as to the success of this treatment. I acknowledge that Dr. Julian Hutchins, Sr. MD, has informed me that he functions only as an educator and consultant not as the primary care physician for any patient. I have assured him that I have another primary physician and do not/will not rely on Dr. Julian Hutchins, Sr. MD for that role.

PATIENT BASIC INFORMATION

SEX

 

HOW DID YOU HEAR ABOUT US?

(please check all that apply)

 

EMERGENCY CONTACTS

 

FINANCIAL POLICY

Thank you for selecting Bee-Lite Medical Weight Loss-Evans, LLC for your health care. We are honored to be of service to you and
your family. This is to inform you of our billing requirements and our financial policy. Please be advised that payment for all
services will be due at the time services are rendered. For your convenience we accept Visa, MasterCard, American Express and
Cash.

 

HIPPA PRIVACY NOTICE

 

PATIENT INFORMED CONSENT FOR APPETITE SUPPRESSANTS

  1. I understand and acknowledge that treatment by Bee-Lite Medical Weight Loss, Dr. Julian Hutchins, Sr., MD and their designated assistants is limited solely to assistance with weight reduction efforts. This treatment does not provide a substitute or replacement for any regular physician. Bee-Lite Medical Weight Loss, LLC and Dr. Julian Hutchins, Sr., MD does not treat acute or chronic medical problems, and I agree to see my regular physician for these problems.
    1. I authorize Dr. Julian Hutchins, Sr., MD and whomever he designates as his assistants to assist me in my weight reduction efforts. I understand my treatment may involve but not be limited to, the use of appetite suppressants for more than 12 weeks and when indicated in higher doses than the dose indicated in the appetite suppressant labeling. I understand that my program may consist of a balanced deficit diet, a regular exercise program, and instructions in behavior modification techniques, and may involve the use of appetite suppressant medications.
    2. I have read and understand my doctor's statements that follow:
      “Medications, including the appetite suppressants, have labeling worked out between the makers of the medication and Food and Drug Administration. This labeling contains, among other things, suggestions for using the medication. The appetite suppressant labeling suggestions are generally based on shorter term studies (up to 12 weeks) using the dosages indicated in the labeling.”
      “As a physician, I have found the appetite suppressants helpful for periods far in excess of 12 weeks, and at times in larger doses than those suggested in the labeling. As a physician, I am not required to use the medication as the labeling suggests, but I do use the labeling as a source of information along with my own experience, the experience of my colleagues, recent longer term studies and recommendations of university based investigators. Based on these, I have chosen, when indicated, to use the appetite suppressants for longer periods of time and at times, in increased doses.”
      “Such usage has not been as systematically studied as that suggested in the labeling and it is possible, as with most other medications, that there could be serious side effects (as noted below).”
      “As a physician, I believe the probability of such side effects is outweighed by the benefit of the appetite suppressant use for longer periods of time and when indicated in increased doses. However, you must decide if you are willing to accept the risks of side effects, even if they might be serious, for the possible help the appetite suppressants use in this manner may give.”
    3. I understand it is my responsibility to follow the instructions carefully and to report to the doctor treating me for my weight any significant medical problems that I think may be related to my weight control program as soon as reasonably possible.
    4. I understand the purpose of this treatment is to assist me in my desire to decrease my body weight and maintain this weight loss. I understand my continuing to receive the appetite suppressant will be dependent on my progress in weight reduction and weight maintenance.
    5. I understand there are other ways and programs that can assist me in my desire to decrease my body weight and to maintain this weight loss.

    In particular, a balanced calorie counting program or an exchange eating program without the use of the appetite suppressant would likely prove successful if followed, even though I would probably be hungrier without the appetite suppressant.

    1. RISKS OF PROPOSED TREATMENT:
      I understand this authorization is given with the knowledge that the use of the appetite suppressants for more than twelve weeks and in higher doses than the dose indicated in the labeling involves some risks and hazards. The more common include: nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, psychological problems, medication allergies, high blood pressure, rapid heartbeat and heart irregularities. Less common, but more serious, risks are primary pulmonary hypertension and valvular heart disease. These and other possible risks could, on occasion, be serious or fatal.
    2. NO GUARANTEE:
      I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I also understand that I will have to continue watching my weight all my life if I am to be successful.
    3. PATIENT'S CONSENT:
      I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained, or any questions I have concerning them have not been answered to my complete satisfaction, I have been urged to take all the time I need in reading and understanding this form and in talking with my doctor regarding risks associated with the proposed treatment and regarding other treatments not involving the appetite suppressants. I also understand that participation in this program is strictly voluntary and is my choice to participate or not. I understand that I may discontinue this treatment at any time at my discretion.
    4. WARNING:
      IF YOU HAVE ANY QUESTION AS TO THE RISKS OR HAZARDS OF THE PROPOSED TREATMENT, OR ANY QUESTIONS WHATSOEVER CONCERNING THE PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK YOUR DOCTOR NOW BEFORE SIGNING THE CONSENT SIGNATURE FORM.
 
I have read and fully understand this consent form. I realize I should not sign this form if all items have not been explained to me. My questions have been answered to my complete satisfaction. I have been urged and have been given all the time I need to read and understand this form.
(If you have any questions regarding the risks or hazards of the proposed treatment, or any questions whatsoever concerning the proposed treatment or other possible treatments, ask your doctor now before signing this consent form.)

 

PATIENT MEDICAL HISTORY

Present Health Status:
  1. Are you in good health at the present time, to the best of your knowledge?

    If "No", explain:

     

  2. Are you under a doctor's care at the present time?

    If "Yes", explain:

     

  3. Are you taking any medications at the present time?

    Prescription Drugs (List all) (Check box to note if medication is Prescription or Over the Counter)
Name of MedicationPrescriptionOver the CounterDosageSchedule
  1. Any allergies to sulfa/sulfur type medications or any other medications?
MedicationReaction
Do you have any of the following:
  1. History of High Blood Pressure?

     

  2. History of Diabetes?


     

  3. History of Heart Attack or Chest Pain or other Heart condition?

    If "Yes", explain.

     

  4. History of Swelling Feet?

     

  5. History of Frequent:

    Medications for Headaches/Migraines:

     

  6. History of Constipation? (Difficulty in bowel movements)

     

  7. History of Glaucoma?

     

  8. History of Sleep Apnea?

    Do you use C-PAP?

     

  9. Any Surgery?

    Specify with date:


     

  10. Do you have any other medical problems or concerns?

 

PAST MEDICAL HISTORY

(CHECK ALL THAT APPLY)

 

FAMILY HISTORY

Please complete this section in its entirety.

Tell us of your family's medical history to the best of your ability including these items as they apply:

AgeGeneral HealthDiseasesOverweightCause of Death
Father
Mother
Brother(s)
Sister(s)
Has any blood relative ever had any of the following?

High Blood Pressure:

Kidney Disease:

Heart Attack/Stents/Bypass/Stroke:

At what age did they have their heart/stroke problems?

 

 

LIFESTYLE EVALUATION

  1. Do you drink coffee, soda, or tea?

     

  2. Do you wake up hungry during the night?

     

  3. Previous diets and/or weight loss medications you have tried: list description (or name) and your results:


     

  4. Do you drink alcohol?

    Daily?

    Weekly?

    Occasionally?

     

  5. Smoking Habits (choose only one)





 

CONSENT TO TREATMENT

(WOMEN ONLY)

I understand that Phentermine and other anorectic medications should NOT be taken during pregnancy, due to the chance of damage to the fetus. The medications have been explained to me fully and I am aware of the risks involved.
To the best of my knowledge, I am not pregnant. I am aware of the precautions that should be taken to avoid pregnancy while I am on the medication. If I become pregnant, I will advise both clinic and my OB/GYN immediately.

 

PHYSICIAN DECLARATION

I have explained the contents of this document to the patient and have answered all the patient's related questions, and to the best of my knowledge, I feel the patient has been adequately informed concerning the benefits and risks associated with the use of the appetite suppressants, the benefits and risks associated with the use of the appetite suppressants, the benefits and risks associated with alternative therapies and the risks of continuing in an overweight state. After being adequately informed, the patient has consented to therapy involving the appetite suppressants in the manner indicated above.

 

DISCLOSURE AND CONSENT FORM

TO THE PATIENT (AND OTHERS LEGALLY RESPONSIBLE FOR THE PATIENT): You have the right, as a patient, to be informed about your condition and how integrative and alternative medicine may be applied in a treatment plan. This disclosure is intended to provide an opportunity for you to make an informed decision so that you may give or withhold your consent to treatment that may be considered unconventional by physicians trained only in the United States. NOTICE: Refusal to consent to the integrative and alternative procedure(s) shall not affect your right to future care or treatment.

I voluntarily request that Dr. Julian Hutchins, Sr., MD and other affiliated health care personnel as he may deem necessary, treat my condition (or the condition of the person for whom I am responsible) as described below

I understand that some of, or all of, the following integrative and alternative treatments are planned for me (or the person for whom I am responsible), and I voluntarily consent and authorize the following: Administration of homeopathic remedies, herbal and nutritional therapies, off label use of pharmaceuticals, injectable vitamins and Amino Acids, B12 with or without Lipotropic, Choline, Methionine, Inositol, as well as:

I understand that no warranty or guarantee has been made regarding results of treatment. I realize that there may be risks and hazards related to the planned integrative treatment, including worsening of present symptoms, development of new symptoms (especially detox reactions) and undesirable interactions between various treatments, both conventional and alternative, as well as:

I have been given an opportunity to ask questions about the treatment of this health condition using conventional, integrative and alternative methods. I have had an opportunity to discuss the possible risks and hazards of treatment and non-treatment, and I believe that I have sufficient information to this informed consent. I certify this form has been fully explained to me, that I have read it (or have it read to me), that the blank spaces have been filled in, and that I understand its contents. I also certify that Dr. Julian Hutchins, Sr. MD has provided this Disclosure and Consent Form to me and fully explained the diagnostic and treatment options available and has made no guarantees to me as to the success of this treatment. I acknowledge that Dr. Julian Hutchins, Sr. MD, has informed me that he functions only as an educator and consultant not as the primary care physician for any patient. I have assured him that I have another primary physician and do not/will not rely on Dr. Julian Hutchins, Sr. MD for that role.

PATIENT BASIC INFORMATION

SEX

 

HOW DID YOU HEAR ABOUT US?

(please check all that apply)

 

EMERGENCY CONTACTS

 

FINANCIAL POLICY

Thank you for selecting Bee-Lite Medical Weight Loss-Evans, LLC for your health care. We are honored to be of service to you and
your family. This is to inform you of our billing requirements and our financial policy. Please be advised that payment for all
services will be due at the time services are rendered. For your convenience we accept Visa, MasterCard, American Express and
Cash.

 

HIPPA PRIVACY NOTICE

 

PATIENT INFORMED CONSENT FOR APPETITE SUPPRESSANTS

  1. I understand and acknowledge that treatment by Bee-Lite Medical Weight Loss, Dr. Julian Hutchins, Sr., MD and their designated assistants is limited solely to assistance with weight reduction efforts. This treatment does not provide a substitute or replacement for any regular physician. Bee-Lite Medical Weight Loss, LLC and Dr. Julian Hutchins, Sr., MD does not treat acute or chronic medical problems, and I agree to see my regular physician for these problems.
    1. I authorize Dr. Julian Hutchins, Sr., MD and whomever he designates as his assistants to assist me in my weight reduction efforts. I understand my treatment may involve but not be limited to, the use of appetite suppressants for more than 12 weeks and when indicated in higher doses than the dose indicated in the appetite suppressant labeling. I understand that my program may consist of a balanced deficit diet, a regular exercise program, and instructions in behavior modification techniques, and may involve the use of appetite suppressant medications.
    2. I have read and understand my doctor's statements that follow:
      “Medications, including the appetite suppressants, have labeling worked out between the makers of the medication and Food and Drug Administration. This labeling contains, among other things, suggestions for using the medication. The appetite suppressant labeling suggestions are generally based on shorter term studies (up to 12 weeks) using the dosages indicated in the labeling.”
      “As a physician, I have found the appetite suppressants helpful for periods far in excess of 12 weeks, and at times in larger doses than those suggested in the labeling. As a physician, I am not required to use the medication as the labeling suggests, but I do use the labeling as a source of information along with my own experience, the experience of my colleagues, recent longer term studies and recommendations of university based investigators. Based on these, I have chosen, when indicated, to use the appetite suppressants for longer periods of time and at times, in increased doses.”
      “Such usage has not been as systematically studied as that suggested in the labeling and it is possible, as with most other medications, that there could be serious side effects (as noted below).”
      “As a physician, I believe the probability of such side effects is outweighed by the benefit of the appetite suppressant use for longer periods of time and when indicated in increased doses. However, you must decide if you are willing to accept the risks of side effects, even if they might be serious, for the possible help the appetite suppressants use in this manner may give.”
    3. I understand it is my responsibility to follow the instructions carefully and to report to the doctor treating me for my weight any significant medical problems that I think may be related to my weight control program as soon as reasonably possible.
    4. I understand the purpose of this treatment is to assist me in my desire to decrease my body weight and maintain this weight loss. I understand my continuing to receive the appetite suppressant will be dependent on my progress in weight reduction and weight maintenance.
    5. I understand there are other ways and programs that can assist me in my desire to decrease my body weight and to maintain this weight loss.

    In particular, a balanced calorie counting program or an exchange eating program without the use of the appetite suppressant would likely prove successful if followed, even though I would probably be hungrier without the appetite suppressant.

    1. RISKS OF PROPOSED TREATMENT:
      I understand this authorization is given with the knowledge that the use of the appetite suppressants for more than twelve weeks and in higher doses than the dose indicated in the labeling involves some risks and hazards. The more common include: nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, psychological problems, medication allergies, high blood pressure, rapid heartbeat and heart irregularities. Less common, but more serious, risks are primary pulmonary hypertension and valvular heart disease. These and other possible risks could, on occasion, be serious or fatal.
    2. NO GUARANTEE:
      I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I also understand that I will have to continue watching my weight all my life if I am to be successful.
    3. PATIENT'S CONSENT:
      I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained, or any questions I have concerning them have not been answered to my complete satisfaction, I have been urged to take all the time I need in reading and understanding this form and in talking with my doctor regarding risks associated with the proposed treatment and regarding other treatments not involving the appetite suppressants. I also understand that participation in this program is strictly voluntary and is my choice to participate or not. I understand that I may discontinue this treatment at any time at my discretion.
    4. WARNING:
      IF YOU HAVE ANY QUESTION AS TO THE RISKS OR HAZARDS OF THE PROPOSED TREATMENT, OR ANY QUESTIONS WHATSOEVER CONCERNING THE PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK YOUR DOCTOR NOW BEFORE SIGNING THE CONSENT SIGNATURE FORM.
 
I have read and fully understand this consent form. I realize I should not sign this form if all items have not been explained to me. My questions have been answered to my complete satisfaction. I have been urged and have been given all the time I need to read and understand this form.
(If you have any questions regarding the risks or hazards of the proposed treatment, or any questions whatsoever concerning the proposed treatment or other possible treatments, ask your doctor now before signing this consent form.)

 

PATIENT MEDICAL HISTORY

Present Health Status:
  1. Are you in good health at the present time, to the best of your knowledge?

    If "No", explain:

     

  2. Are you under a doctor's care at the present time?

    If "Yes", explain:

     

  3. Are you taking any medications at the present time?

    Prescription Drugs (List all) (Check box to note if medication is Prescription or Over the Counter)
Name of MedicationPrescriptionOver the CounterDosageSchedule
  1. Any allergies to sulfa/sulfur type medications or any other medications?
MedicationReaction
Do you have any of the following:
  1. History of High Blood Pressure?

     

  2. History of Diabetes?


     

  3. History of Heart Attack or Chest Pain or other Heart condition?

    If "Yes", explain.

     

  4. History of Swelling Feet?

     

  5. History of Frequent:

    Medications for Headaches/Migraines:

     

  6. History of Constipation? (Difficulty in bowel movements)

     

  7. History of Glaucoma?

     

  8. History of Sleep Apnea?

    Do you use C-PAP?

     

  9. Any Surgery?

    Specify with date:


     

  10. Do you have any other medical problems or concerns?

 

PAST MEDICAL HISTORY

(CHECK ALL THAT APPLY)

 

FAMILY HISTORY

Please complete this section in its entirety.

Tell us of your family's medical history to the best of your ability including these items as they apply:

AgeGeneral HealthDiseasesOverweightCause of Death
Father
Mother
Brother(s)
Sister(s)
Has any blood relative ever had any of the following?

High Blood Pressure:

Kidney Disease:

Heart Attack/Stents/Bypass/Stroke:

At what age did they have their heart/stroke problems?

 

 

LIFESTYLE EVALUATION

  1. Do you drink coffee, soda, or tea?

     

  2. Do you wake up hungry during the night?

     

  3. Previous diets and/or weight loss medications you have tried: list description (or name) and your results:


     

  4. Do you drink alcohol?

    Daily?

    Weekly?

    Occasionally?

     

  5. Smoking Habits (choose only one)





 

CONSENT TO TREATMENT

(WOMEN ONLY)

I understand that Phentermine and other anorectic medications should NOT be taken during pregnancy, due to the chance of damage to the fetus. The medications have been explained to me fully and I am aware of the risks involved.
To the best of my knowledge, I am not pregnant. I am aware of the precautions that should be taken to avoid pregnancy while I am on the medication. If I become pregnant, I will advise both clinic and my OB/GYN immediately.

 

PHYSICIAN DECLARATION

I have explained the contents of this document to the patient and have answered all the patient's related questions, and to the best of my knowledge, I feel the patient has been adequately informed concerning the benefits and risks associated with the use of the appetite suppressants, the benefits and risks associated with the use of the appetite suppressants, the benefits and risks associated with alternative therapies and the risks of continuing in an overweight state. After being adequately informed, the patient has consented to therapy involving the appetite suppressants in the manner indicated above.

 

DISCLOSURE AND CONSENT FORM

TO THE PATIENT (AND OTHERS LEGALLY RESPONSIBLE FOR THE PATIENT): You have the right, as a patient, to be informed about your condition and how integrative and alternative medicine may be applied in a treatment plan. This disclosure is intended to provide an opportunity for you to make an informed decision so that you may give or withhold your consent to treatment that may be considered unconventional by physicians trained only in the United States. NOTICE: Refusal to consent to the integrative and alternative procedure(s) shall not affect your right to future care or treatment.

I voluntarily request that Dr. Julian Hutchins, Sr., MD and other affiliated health care personnel as he may deem necessary, treat my condition (or the condition of the person for whom I am responsible) as described below

I understand that some of, or all of, the following integrative and alternative treatments are planned for me (or the person for whom I am responsible), and I voluntarily consent and authorize the following: Administration of homeopathic remedies, herbal and nutritional therapies, off label use of pharmaceuticals, injectable vitamins and Amino Acids, B12 with or without Lipotropic, Choline, Methionine, Inositol, as well as:

I understand that no warranty or guarantee has been made regarding results of treatment. I realize that there may be risks and hazards related to the planned integrative treatment, including worsening of present symptoms, development of new symptoms (especially detox reactions) and undesirable interactions between various treatments, both conventional and alternative, as well as:

I have been given an opportunity to ask questions about the treatment of this health condition using conventional, integrative and alternative methods. I have had an opportunity to discuss the possible risks and hazards of treatment and non-treatment, and I believe that I have sufficient information to this informed consent. I certify this form has been fully explained to me, that I have read it (or have it read to me), that the blank spaces have been filled in, and that I understand its contents. I also certify that Dr. Julian Hutchins, Sr. MD has provided this Disclosure and Consent Form to me and fully explained the diagnostic and treatment options available and has made no guarantees to me as to the success of this treatment. I acknowledge that Dr. Julian Hutchins, Sr. MD, has informed me that he functions only as an educator and consultant not as the primary care physician for any patient. I have assured him that I have another primary physician and do not/will not rely on Dr. Julian Hutchins, Sr. MD for that role.