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Patient Weight Loss Questionnaire

1. To continue the consultation process, please enter your information below.

Gender:

History Of Present Illness

9. Weight Issues as a Child?
10. Past Medical History
11. Family History
12. Past Surgical History
14. Contraindications
15. Exercise Level

Return Policy 
The Trim Clinics are a medical clinic providing the latest safe and effective treatments for weight loss. The 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 are 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 Trim Clinics do not offer refunds on accounts with outstanding claims or balances; or where upcoming services are scheduled.
2. The Trim Clinics do not allow the transfer of services to other individuals or other clinics.
3. Submission of the returned product does not constitute acceptance of the return. The Trim Clinics reserves the right to determine whether the products or services qualify for replacement/refund. The 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 Trim Clinic do accept the return or refund of:
1. Recalled
2. Incorrect shipments
3. Damaged product due to shipping carrier
Items Deemed Non-Returnable
The 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 Trim Clinics will provide two (2) additional trainings at no cost to the patient.
2. Products or services not purchased directly from The Trim Clinics; The Trim Clinics reserves the right to destroy non-Trim Clinic products shipped as a returned product and to charge the patient for the cost incurred to process and destroy the non-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 Trim Clinics 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 Trim Clinics or any other pharmacies used by The Trim Clinics or government agency, The Trim Clinics agrees to pay reasonable out-of-pocket costs for costs incurred by the patient.
b. The 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 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 Clinics 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 Trim Clinic 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 Trim Clinic will use all documentation available to refute the charge back including patient acknowledgment of the refund policy.






Please Read & Sign
Dear Patient

Today you will receive a consultation by a clinic staff member regarding our weight loss program. After you speak with our physician he or she will decide whether or not you are a candidate for treatment with the GLP-1 (SemaGlutide) medication for weight loss, and or B12 booster shot. The medication is self-administered subcutaneously weekly for the GLP-1 medication or self-administered to the intra muscular area on a monthly for the B12 booster shot. 

You may experience side effects such as nausea, stomach cramping, headaches, indigestion, constipation, loose stool, pain/redness at the injection site as you are adjusting to the medication. If side effects are experienced, they are typically mild and relieved with over the counter remedies. Candidates with a family history of Thyroid Cancer or Multiple Endocrine Neoplasia Syndrome or a history of Pancreatitis will be precluded from being prescribed the GLP-1 medication as these are contraindications. 

I,                                   , fully understand the nature of the medication described above and the possible side effects. I agree to pay a medical consultation fee of $97 upon completion of my visit and I am aware that the purchase of my self-elected medications are final. I understand I am enrolling in a weight loss program but should the doctor not approve me medically to receive the treatment my initial payment of $97 will be refunded if already charged. Any payment beyond the initial consultation fee will also be refunded in the manner it was paid if I don't qualify for the B12 and/or GLP-1 medication (SemaGlutide). I understand my monthly participation fee (recurring monthly charge) which covers my ongoing monitoring and my medication will be charged automatically each month. I consent to treatment by The Lipo Lounge physician(s). I acknowledge these services are considered to be elective treatments and that they 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 anytime, however, I must provide The Lipo Lounge notice before they place my next monthly order.

FOR OFFICE USE ONLY- LEAVE BLANK

Medication Approved
B-12 Shot Approved
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