Champion Health and Wellness Clinics

4295 San Felipe St., Ste. 235 Houston TX 77027
281-501-0611

Patient Consent Form

Phentermine Onboarding Process

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PHENTERMINE INFORMED CONSENT

I request the use of Phentermine, along with dietary restrictions for the purpose of weight loss. I understand that as part of the program, I will be given a limited physical orientation to the programs with supporting materials and I will be instructed on how to administer Phentermine myself. I understand that initial blood tests may be necessary to rule out any conditions that could limit or restrict you from being prescribed phentermine. I understand there is no guarantee for the effectiveness of Phentermine.

Prior to my treatment, I have fully disclosed any medical conditions or diseases such as history of gallbladder disease, diabetes, autoimmune diseases, HIV, heart disease, liver disease, kidney disease, uncontrolled high blood pressure, seizure disorders, blood disorder (anemia, thalessemia, hemophilia) 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(s) that I have, I release CHAMPION HEALTH AND WELLNESS CLINCS from any liability associated with this treatment. Initials:

What is the most important information I should know about Phentermine?

Weight loss during pregnancy can harm an unborn baby, even if you are overweight. Do not use Phentermine if you are pregnant.

Do not use Phentermine if you have used an MAO inhibitor such as furazolidone (Furoxone), isocarboxazide (Marplan), phenelzine (Nardil), rasagiline Azilect), selegiline (Eldepryl, Emsam, Zelapar) or tranylcypromine (Parnate) in the last 14 days. A dangerous drug interaction could occur, leading to serious side effects.

Taking Phentermine together with other diet medications such as fenfluramine (PhenFen) or dexfenfluramine (Redux) can cause a rare fatal lung disorder called pulmonary hypertension. Do not take Phentermine with any other diet medications without your doctor’s advice.

Phentermine may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be alert.
Drinking alcohol can increase certain side effects of this medicine.

Phentermine is only part of a complete program of treatment that may also include diet, exercise, and weight control. Follow your diet, medication, and exercise routines very closely. Phentermine may be habit forming and should be used only by the person it was prescribed to.
Never share Phentermine with another person, especially someone with a history of drug abuse or addiction.
Keep track of the amount of medicine used from each new bottle.
Phentermine is a drug of abuse and you should be aware if anyone is using your medicine improperly or without a prescription.

Do not stop using Phentermine suddenly, or you could have unpleasant withdrawal symptoms.
Ask your doctor how to avoid withdrawal symptoms when you stop using this medicine.

How should I take Phentermine?

Take Phentermine exactly as prescribed by your doctor. Do not take in larger or smaller amounts or for longer than recommended. Follow the directions on your prescription label. Some brands of Phentermine should be taken on an empty stomach before breakfast or within 2 hours after breakfast.

Suprenza disintegrating tablets can be taken with or without food. Using dry hands, remove the Suprenza tablet from the medicine bottle and place the tablet in your mouth. It will begin to dissolve right away. Do not swallow the tablet whole, allow it to dissolve in your mouth without chewing.

To prevent sleep problems, take this medication early in the day, no later than 6:00 pm. Talk with your doctor if you have increased hunger or if you otherwise think the medication is not working properly. Taking more of this medication will not make it more effective and can cause serious, life threatening side effects. Store at room temperature away from moisture and heat.

What happens if I miss a dose? Take the missed dose as soon as you remember. Skip the missed dose if it is almost time for your next scheduled dose. Do not take extra medicine to make up the missed dose What happens if I overdose? Seek emergency medical attention or call the

Poison Help line at 1-800-222-1222.

An overdose of Phentermine can be fatal. Overdose symptoms may include confusion, hallucinations, panic, feeling hostile or aggressive, nausea,vomiting, diarrhea, stomach cramps, irregular heartbeat, rapid breathing, overactive reflexes, confusion, seizure (convulsions), feeling light-headed, or fainting.

What should I avoid while taking Phentermine? Drinking alcohol can increase certain side effects of this medicine. Phentermine may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be alert.

Phentermine Dosing Information

Usual Adult Phentermine Dose for Weight Loss:

Phentermine hydrochloride and phentermine resin may be given as a single dose of 15-37.5 mg orally once a day before breakfast or 10‐14 hours before going to bed.

Usual Pediatric Phentermine Dose for Weight Loss: Child > 12 years:

Initial dose: 8 mg orally 3 times a day 30 minutes before meals. Alternatively, phentermine hydrochloride and phentermine resin may be given as a single dose of 15-37.5 mg orally once a day before breakfast or 10-14 hours before going to bed.

Signed Consent of Risks

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