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617 Harborview Drive | Smithville, Missouri 64089

With any drug, there is the possibility of an allergic reaction or unusual reaction that may cause skin rash, difficulty breathing, collapse, or even death.

HCG is virtually free of negative side effects, but you must follow a very low-calorie, low-fat diet that can sometimes trigger a gallbladder attack in individuals who are genetically pre-disposed to gallbladder disease.

Your medication will be discontinued if there is a severe adverse reaction.

I understand that the program and medications may involve risk. I have read and understood the information given to me about the medications. I have asked and answered any questions that I may have after reading this form. I understand the possible side effects and agree to advise Meta-Health Weight Management, Inc. should they occur. I understand that I may quit the program at any time. I agree to stop the HCG if I become pregnant and agree to advise Meta-Health Weight Management, Inc. should I decide to become pregnant. No adverse side effects or complications are expected, but in the event that an illness does occur, I understand that I need to contact Meta-Health Weight Management, Inc. If I experience an emergency situation, I understand that I need to go to an emergency facility. I authorize Meta-Health Weight Management, Inc. to use my photos for advertising purposes as needed.

I warrant to the Company that I am in good health and fully able to participate in the Program and that any questions concerning my ability to participate in the Program have been or will be discussed with my doctor before I participate. I acknowledge that I am responsible for my own health and I release the Company and its officers, employees, and agents from any and all claims, liabilities, or damages for personal injuries which I may suffer directly or indirectly resulting from my participation in the Program. I fully understand that employees of the Company are not health practitioners, and cannot be expected to diagnose or treat individual health problems and that all such questions should be addressed by me to my own physician and I agree to do so.

HCG Weight Loss Program Getting Started

HCG is a prescription medication used by Meta-Health Weight Management, Inc. in its weight loss program.

Personal Information

Medical History

Medical History
Medical History (continued)
Medical History (continued)

Diet History

The client is informed that the Medical Eligibility Form is only a screening to begin the weight loss program. A regularly scheduled examination should be performed by your primary physician as needed.

I have read and completed the Medical Eligibility information. I have answered all the questions to the best of my knowledge. I understand that Meta-Health program uses medications that may affect other medications I am currently taking. I agree to discuss my enrollment in the Meta-Health program with my physician. I understand that if my physician does not feel that the program is suitable for my health status I will discontinue the program. I agree to inform the Meta-Health provider and my primary physician of any changes in my health status.

SUBMIT
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