Sure Success Weight Loss Center, 5420 N. College Ave, Suite L7, Indpls, IN 46220
HCG CONSENT
Patient Name: ________________________________________
The Use of HCG for Weight Loss is Not an FDA Approved Use
The FDA has not approved the use of HCG for weight loss treatment, obesity therapy or determined
that the use of HCG contributes to an individual’s loss of body fat. The FDA, National Institute of
Health and the manufacturers of HCG advise that "HCG has no known affect on fat mobilization,
reducing appetite or sense of hunger, or body fat distribution." and they further state that "HCG has
not been demonstrated to be an effective adjunct therapy in the treatment of obesity and does not
increase fat losses beyond that resulting from caloric restriction."
HCG is Prescribed for Weight Loss at the Discretion of Physician
Use of HCG to treat obesity or for medical weight loss treatment is not an FDA approved use of this
prescription drug. A patient's physician may prescribe HCG for an unapproved medical purpose or offlabel use of the drug because the use of this drug has not generally caused serious adverse side
effects when administered to patients for its approved use in treating infertility. Allowing physicians
professional discretion to prescribe HCG in treating obesity or for patient weight loss is not based upon
any governmental determination that HCG is effective for such use.
The Use of HCG to treat obesity or for use in a medical weight loss treatment combined with a low
carb, low fat and low sugar diet with recommended exercise is not an FDA approved use of HCG and is
prescribed at the discretion of the patient's physician based upon the physician's clinical assessment of
the patient's medical complaint, medical history, physical examination results and diagnostic
laboratory report combined with the perceived benefit to be derived by the patient from the
medication when combined with a healthy diet plan and exercise.
Medical Disorders Revealed by Physical Exam or Lab
A patient’s medical laboratory diagnostic tests or physical exam may reveal other medical conditions
or disorders indicating the need for medical treatment other than, or in addition to, medical weight
loss treatment . The diagnostic and physician fees and costs associated with such other medical
conditions are not included in the above for fees for this single therapy. The patient shall be referred
to their primary care physician or a physician specialist with regard to medical treatments not
provided by our clinic.
I have read the above, asked questions and fully understand the
agreement to start this treatment program for weight loss. I realize
that I should not sign this form if all items have not been explained,
or any questions I have concerning them have not been answered to
my complete satisfaction. If I violate the agreement, I will be
released from the program.
Patient Signature: ________________________ Date: _________
Physician Signature: ________________________Date: ________