HEALTH HISTORY

CONSENT FOR WEIGHT LOSS PROGRAM

This consent form outlines the details of The Lipo Lounge Trim Clinics weight loss program. As part of this program, you will undergo an evaluation by Dr. Anjmun Sharma or a Nurse Practitioner to determine whether you are a candidate for treatment with GLP-1 medication for weight loss and/or B Complex. The GLP-1 medication is self-administered subcutaneously on a weekly basis.

Possible side effects of the medication may include nausea, stomach cramping, headaches, indigestion, constipation, loose stool, or pain/redness at the injection site. These side effects are typically mild and may be relieved with over-the-counter remedies. Candidates with a family history of Thyroid Cancer, Multiple Endocrine Neoplasia Syndrome, or a history of Pancreatitis will not be prescribed the GLP-1 medication or B Complex, as these are contraindications.

I understand my monthly participation fee (recurring monthly charge), which covers my ongoing monitoring and medication, will be charged automatically each month or may be paid month to month. I consent to treatment by The Lipo Lounge Trim Clinic physician, Dr. Anjmun Sharma, or Nurse Practitioners. I acknowledge these services are considered to be elective treatments and are not covered by Medicare or most insurance providers. Any medications ordered by me are non-returnable in accordance with applicable laws. I understand that I can cancel at any time; however, I must provide The Lipo Lounge Trim Clinic with notice before my next monthly order is placed.

I have read and fully understand the information provided regarding the weight loss program, the medications involved, and the potential side effects. I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction. I voluntarily consent to participate in this program and to receive treatment as recommended by the medical provider. I acknowledge that I understand the terms outlined in this consent form.

RETURN POLICY

The Lipo Lounge Trim Clinics are a medical clinic providing the latest safe and effective treatments for weight loss. The Lipo Lounge Trim Clinics are a cash clinic that does not accept medical insurance. We provide full paperwork for patients to seek reimbursement for any services and prescription medications that may be covered by the patient’s insurance. Payment for services is the responsibility of the patient regardless of insurance coverage. This return policy constitutes the only conditions applying to the return of products and services, no other policy to this effect exists, and this policy supersedes all prior policies. 

GENERAL 

1. The Lipo Lounge Trim Clinics does not offer refunds on accounts with outstanding claims or balances; or where upcoming services are scheduled.

2. The Lipo Lounge Trim Clinics do not allow the transfer of services or treatments to other individuals or other clinics. 

3. Submission of the returned product does not constitute acceptance of the return. The Lipo Lounge Trim Clinics reserves the sole right to determine whether the products or services qualify for replacement/refund. The Lipo Lounge Trim Clinics also reserves the sole right to refuse a return as it deems appropriate. 

4. Refunds less than $25.00 will not be processed. 

ITEMS DEEMED RETURNABLE 

The Lipo Lounge Trim Clinics will not issue a refund, but will promptly replace items meeting the following criteria: 

1. Recalled products. 

2. Incorrect shipments 

3. Damaged product due to shipping carrier 

ITEMS DEEMED NON-RETURNABLE

The Lipo Lounge Trim Clinics do not accept the return or refund of: 

1. Services provided or performed; including but not limited to physician visits and patient training. If initial patient training was unsuccessful. The Lipo Lounge Trim Clinics will provide two (2) additional trainings at no cost to the patient. 

2. Products or services not purchased directly from The Lipo Lounge Trim Clinics; The Lipo Lounge Trim Clinics reserves the right to destroy non-Lipo Lounge Trim Clinic products shipped as a returned product and to charge the patient for the cost incurred to process and destroy the non-Lipo Lounge Trim Clinic product. 

3. Prescription medications, including but not limited to any prescription written by a licensed physician. 

4. Damaged products, including but not limited to missing or damaged labels, repackaged product, opened product, and product otherwise not in its original form. 

5. Mishandled products, due to patient's improper handling or storage of the products. 

PROCESS FOR RETURNS/REFUNDS 

The Lipo Lounge Trim Clinic will only accept the return of product for consideration of refund, if applicable, under the following conditions:

1. For recalled products: 

     a. In the event of a recall initiated by The Lipo Lounge Trim Clinics, or any other pharmacies used by The Lipo Lounge Trim Clinics, or government agency, The Lipo Lounge Trim Clinics agrees to pay reasonable out-of-pocket costs for costs incurred by the patient. 

     b. The Lipo Lounge Trim Clinics will provide the patient with instructions on how to return any recalled product. 

2. For incorrect shipments, and products damaged due to shipping carrier: 

    a. The Lipo Lounge Trim Clinics must be notified within seven (7) days of the incorrect of damaged shipment. Please contact the main office at 858-679-5544. 

    b. Mail the product via USPS to Address 

    c. Damaged products will be replaced, not refunded, within seven (7) business days after receipt of an approved return.

CANCELLATION OF FUTURE PURCHASES

If the patient chooses to discontinue participation in the monthly subscription service to receive medication, the patient must inform The Trim Clinic Lipo Lounge in writing or phone call, before the monthly ordering takes place. Failure to do so may result in a cancellation charge. 

CHARGEBACKS INITIATED BY THE PATIENT 

The Lipo Lounge Trim Clinics takes patient care very seriously, and our clinics strive to provide the highest quality care to every individual. In the event the patient is not satisfied, we ask he please refer to this document rather than initiating a charge back with his or her credit card company. If a charge back is initiated, The Lipo Lounge Trim Clinics will use all documentation available to refute the charge back including patient acknowledgment of the refund policy. 

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