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Thank you for choosing Naperville Weightloss Center! It is our mission to provide comprehensive, tailored treatment to all our patients. To give this quality of care, we ask that you adhere to our Practice Policies, Patient Responsibilities, & Informed Consent.
Cancellations & No-show Appointments I will notify the office at least 24 hours prior to your scheduled appointment time if you are unable to attend. If I arrive more than 10 minutes after your scheduled appointment time, it is up to the provider’s discretion to keep your appointment. Canceling less than 24 hours in advance, arriving more than 10 minutes late, or no-show may result in a non-refundable $25 fee to the credit card on file. Due to unexpected and crisis situations, providers and staff request patience while waiting.
Insurance Insurance is not accepted at this clinic and all fees are my responsibility. I am aware insurance information may be requested for use of prescription prior authorizations. I authorize Naperville Weightloss Center to release to my insurance company or its representative, information requested including but not limited to my diagnosis and records of my treatment by this practice.
I understand that some medications prescribed may be used ‘off-label’ for weight loss and insurance may not cover the cost of the medication. If not covered, I will notify clinic to discuss alternative medication options or pay for the medication out-of-pocket. I am responsible for the cost of medication, except for phentermine 37.5mg from Total Care Pharmacy at 4300 Weaver Parkway, Warrenville, IL 60555. I am aware that NWLC cannot be held accountable for any out-of-pocket costs due to medication denied by insurance.
Medical I agree to be under the care of a primary care physician. will inform Naperville Weightloss Center of any changes to my medical status, such as medication changes or diagnoses. All the medical/surgical information I have given to Naperville Weightloss Center is correct and complete to the best of my knowledge. I understand that dietary management and physical exercise are necessary components of this program and must be utilized for optimum results. I have not been given any guarantees or promises regarding the expectations or results. I understand that weight loss alone carries some risk, including gallbladder disease. I freely and voluntarily consent to participate and agree to follow the instructions given.
Diabetes I understand that if I am ever to be diagnosed with Type 2 Diabetes Mellitus, I will follow up with a PCP or specialist for my diabetic care. Although some medications prescribed may help lower my A1c, I will continue to follow up with my diabetic provider for routine labs, health screenings, referrals, medication adjustments, and any other questions/concerns regarding my diabetic diagnosis.
Medications I understand that medications used in this program may have side effects and/or adverse reactions. These may include high blood pressure or altered insulin requirements in diabetics. I agree to stop taking the medication IMMEDIATELY, seek medical attention, and report to this office if any of the following occurs: decreased exercise tolerance, leg swelling, unexplained shortness of breath, chest pain, blurred vision, or altered consciousness.
GLP-1 I have been made aware of the black-box warning of medullary thyroid cancer with use of GLP-1 agonists (such as semaglutide, dulaglutide, liraglutide, etc.). I understand that there may be adverse reactions to the medications, including rapid heart rate, restlessness, agitation, poor sleep, dizziness, headaches, blurred vision, psychosis, dry mouth, constipation, diarrhea, nausea, stomach pains, frequent urination or discomfort urination, changes in sex drive, pancreatitis, gastroparesis, gallbladder disease, hypoglycemia, and dehydration. If obtaining a GLP-1 from a compounding pharmacy, I am aware that this medication is not FDA approved and will not hold Naperville Weightloss Center liable for any adverse effects or reactions that may occur due to compounding.
Stimulants I understand that it is not permitted to obtain appetite suppressants from more than one prescriber or clinic. I will not obtain appetite suppressant prescriptions filled from multiple pharmacies. Random pill counts and drug screens may be conducted for your safety and compliance monitoring.
Medication Safety Use medication only as prescribed. Do not increase or decrease dose or frequency, or abruptly stop taking medication without your prescriber’s knowledge or permission. Keep medications and prescriptions in a secure, safe place preventing others’ access to these medications. Do not share or sell medications to anyone, including family members, as state and federal law prohibit this. Do not use alcohol or illegal substances while taking medications or while driving. Tolerance can occur with the use of some medications. Tolerance is defined as a need for a higher dose to maintain the same effect. If your prescriber determines that continued escalation of the dose is not in your best interest, these medications may need to be discontinued or may necessitate switching to another form of treatment. Your prescriber may choose to discontinue your medication, including controlled substances, if he/she believes that your: condition is not improving, medication usage is escalating, or if you begin to experience unacceptable side effects.
Refills Medication refills, early refills, or adjustments only occur during appointments. Medication might not be replaced if lost, destroyed/damaged, or stolen without proper documentation. A police report is required for any stolen or missing controlled substances, including phentermine. Your prescriber reserves the right to deny replacing them at their discretion.
Pregnancy Individuals who have ability to become pregnant: I have been informed that I should NOT get pregnant while on medications and confirm that I am not pregnant or trying to get pregnant at this time. I agree to immediately notify my prescriber if I become pregnant. Medications could be harmful or fatal to the fetus. I agree to hold Naperville Weightloss Center harmless from any claims or lawsuits if I should get pregnant while taking medications prescribed by Naperville Weightloss Center.
Urgent Matters/Emergencies If I should have any questions about prescribed medications from the clinic, I will ask the clinic prescriber or staff. In the event of adverse medication side effects or urgent concerns, the office will try to accommodate these matters within normal business hours, whenever possible. If I experience an emergency, I will call 911 or go to your nearest emergency room.
Notice of Privacy Practices I acknowledge that I have been offered and/or received a written copy of Naperville Weightloss Center Notice of Privacy Practices. This notice provides in detail the uses and disclosures of my protected health information that may be used by this practice, my individual rights, how I may exercise my rights, and Naperville Weightloss Center’s legal dues with respect to my protected health information.
Consent for Treatment I have met with a member of the medical staff, have reviewed the literature associated with the program and have been given the opportunity to have all my questions regarding the weight loss program answered. I hereby give consent to Naperville Weightloss Center to render health services.
By checking this box, I am acknowledging that I have read and agree to the terms written in the practice policies, patient responsibilities and inform consent form for Naperville Weightloss Center. I will sign a physical copy of this form at my initial visit to be kept on file.
We are committed to treating and using protected health information about you responsibly. This Notice of Privacy Policies describes the personal information we collect, and how and when we use or disclose that information. This Notice applies to protected health information as defined by federal regulations.
Understanding Your Health Record/ Information
Each time you visit Naperville Weightloss Center, a record of your visit is made. Typically, this record contains your symptoms, examination, and test results, diagnoses, treatment, and a plan for future care or treatment. Understanding what is in your record and how your health information is used helps you to ensure its accuracy, better understand who, what, when, where, and why others may access your health information and make more informed decisions when authorizing disclosure to others. This information often referred to as your health or medical record, serve as a:
Your Health Information
Although your health record is the physical property of Naperville Weightloss Center, the information belongs to you. You have the right to:
Our Responsibilities
We are required to:
We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you’ve supplied us. We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue using or disclosing your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.
For More Information or to Report a Problem If you have questions and would like additional information, you may contact office administration at 630-416-8289 or
Office for Civil RightsU.S. Department of Health and Human Services 200 Independence Avenue, S.W. Room 509F, HHH BuildingWashington, D.C. 20201
Business Associates: There are some services provided in our organization through contacts with business associates. Examples include billing services and our answering service. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information however, we require the business associate to appropriately safeguard your information.
Marketing: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
FDA: We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recall, repairs, or replacement.
Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Law Enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
By checking this box, I am acknowledging that I have read and agree to the terms written in the Privacy Policy form for Naperville Weightloss Center. I will sign a physical copy of this form at my initial visit to be kept on file.
