FBRC is now offering Semaglutide or Tirzepatide! Under $500 per month with Free shipping to your location.

FBRC is now offering Semaglutide or Tirzepatide! Under $500 per month with Free shipping to your location.

MWL Questionnaire

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Medical Clearance Questionnaire

Do you have a history of Medullary thyroid cancer or a strong family history of Medullary thyroid cancer?
Do you have a history of kidney disease? MWL Meds could worsen the kidneys causing kidney failure.
Do you have a history of pancreatic disease? Although rare, MWL Meds can cause pancreatitis.
Do you have diabetic retinopathy? MWL Meds can worsen this condition.
Do you have a history of chronic depression or suicide ideation? MWL Meds can worsen these conditions.
Are pregnant or planning on being pregnant in the next two months.
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Medical Weight Loss Program Liability Waiver

Participant Information

I, the undersigned participant, acknowledge that I have voluntarily enrolled in the medical weight loss program offered by Trident Primary Care & Wellness Clinic. This program may include, but is not limited to, personalized dietary plans, exercise recommendations, and other health-related guidance.
I am aware that participating in a weight loss program involves certain inherent risks, including but not limited to physical injury, emotional distress, and potential medical complications. I understand that the program may have different effects on individuals and that results are not guaranteed.
I hereby disclose any known medical conditions, allergies, or medications that might affect my ability to safely participate in the weight loss program.
I acknowledge the importance of consulting with my healthcare provider before starting this weight loss program, particularly if I have any pre-existing health conditions or concerns.
I voluntarily assume all risks associated with participating in the weight loss program provided by Trident Primary Care & Wellness Clinic.
I hereby release, discharge, and hold harmless Trident Primary Care & Wellness Clinic, its employees, agents, representatives, and any affiliated parties from all liability, claims, demands, actions, or causes of action related to any loss, damage, or injury, including death, that may be sustained by me during or after participation in the weight loss program.
I understand and agree to comply with all guidelines, instructions, and recommendations provided by Trident Primary Care & Wellness Clinic during the weight loss program.
I acknowledge that any personal or medical information shared during the program will be kept confidential.

Thank you for taking the time to fill out this form.

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