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Additional Consent and Indemnification

Indemnification Clause

By signing this form I agree to indemnify, defend, protect, and hold harmless the medical providers employed by Erica Granteed and/or The District Injector LLC and their respective officers, directors, employees, stockholders, assigns, successors and affiliates (Indemnified Parties) from, against and in respect of all liabilities, losses, claims, damages, judgements, settlement payments, deficiencies, penalties, fines, interest and costs, expenses suffered, sustained, incurred or paid by the indemnified parties, in connection with, results from or arising out of, directly or indirectly, the medical providers employed by Erica Granteed and/or The District Injector LLC; rendering medical care, services, advice, and/or treatment by my failure to disclose all relevant information regarding my medical and physical condition, acts or omissions, the medical providers employed by Erica Granteed and/or The District Injector LLC; harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by the medical providers employed by Erica Granteed and/or The District Injector LLC. I am aware of the potential side effects associated with non-surgical aesthetic medicine treatments, weight loss medications, hormone replacement therapy, and injectable therapies to include IV therapy, provided by The District Injector. I accept all the risks involved with non-surgical aesthetic medicine treatments, weight loss medications, hormone replacement therapy, and IV infusion and injectable therapies, and will not seek indemnification or damages from the indemnified parties.

Clinical Policies – Weight Management

I acknowledge that The District Injector LLC and Erica Granteed AGACNP-BC are not my Primary Care Provider. I agree that I will continue with routine care through my Primary Care Provider, and/or treating Medical Specialists, and will notify them of treatments prescribed at The District Injector LLC.

I agree that if I am having any side effects or become ill, I will notify The District Injector LLC, and follow up with my Primary Care Provider or present to an Urgent Care or Emergency Department.

I understand that having an appointment with The District Injector LLC does not necessarily entitle me to being issued treatment or prescription medications. Every individual is different, and it is at the medical provider’s discretion to issue treatment or prescriptions.

I understand that there are no refunds for services or products rendered. We cannot accept back used medications once they have been dispensed per state regulation.

I understand that I must maintain my follow up appointments to remain on prescription treatments. It is important, if deemed necessary by your provider, to monitor lab work regularly for safety purposes. It is important that The District Injector LLC and Erica Granteed AGACNP-BC manages my treatment, and it is at their discretion to provide treatments.

I agree that I will take my medications as prescribed. I agree to follow my medical provider’s instructions. I also agree that I will not sell or share any prescriptions prescribed to other individuals.

I understand that treatments used at The District Injector LLC might not be considered a medical necessity. Treatments rendered are for the purpose of improving your quality of life through elective cosmetic treatments, hormone restoration, nutritional and supplemental counseling, and possibly weight loss treatment.

Health insurance typically does not cover services provided at The District Injector LLC. If you want to seek insurance reimbursement, we would be happy to provide you with itemized invoices that you can submit to your insurance company.

I acknowledge that I have been advised of the risks and benefits of treatment. I also acknowledge that I have been advised of possible complications and side effects. I understand the risks, benefits, complications, and side effects of treatment.

I am voluntarily requesting treatment with The District Injector and Erica Granteed AGACNP-BC regarding elective cosmetic procedures, hormone replacement therapy, weight loss, and additional treatment modalities as determined by a mutual decision between myself and the medical provider even if my laboratory values, hormone levels, and weight, are considered in normal range for my age based off other medical society recommendations and guidelines.

I hold The District Injector and Erica Granteed, AGACNP-BC harmless if an adverse event occurs during my treatment. I will ensure that my Primary Care Provider, Dermatologist, or other treating Medical Specialist provides the results of positive screenings to The District Injector LLC as this could change the treatment prescribed to me.

  • *If you are late or miss your follow up appointment, you may be subject to a $50 fee.
  • *If you are late or miss your weekly check-in appointment, you may be subject to a $20 fee.
  • *Services must be paid for at the time of service.

Informed Consent for Medically Management Weight Loss Therapy

I acknowledge that I am voluntarily entering into a medically managed weight loss program with The District Injector LLC. I fully realize that entering any program involving weight reduction, which includes moderate calorie restriction, exercise, and medications, involves potential risks and side effects. The risks include, but may not be limited to the following:

1. Cardiovascular (heart or blood pressure): These problems may include heart palpitations, irregular beats, or rapid heartbeat. These effects are usually mild but can result in serious problems including heart attack or stroke. Also, these medications may increase blood pressure, which if left untreated can lead to heart attack or stroke. If you discontinue the weight loss medication, the elevated blood pressure usually resolves. For this reason, if you are on blood pressure medications you are required to monitor your blood pressure daily and discontinue medications if blood pressure rise, your heart rate increases, or you feel palpitations.

2. Sudden Death: Patients with morbid obesity, particularly those with hypertension, heart disease, or diabetes, have a statistically higher chance of suffering sudden death when compared to normal weight people without such medical problems. Rare instances of sudden death have occurred while obese patients were undergoing medically supervised weight reduction, though no cause and effect relationship with the diet has been established. The possibility cannot be excluded that some undefined or unknown factor in the treatment program could increase this risk in an already medically vulnerable patient.

3. Reduced Potassium Levels: The calorie level you will be consuming is 800 or more calories per day and it is important that you consume the calories which have been prescribed in your diet to minimize side effects. Failure to consume all of the food and fluids, nutritional supplements or taking a diuretic medication (water pill) may cause low blood potassium levels or deficiencies in other nutrients. Low potassium levels can cause serious heart irregularities. When someone has been on a reduced calorie diet, a rapid increase in calorie intake, especially overeating or binge-eating, can be associated with bloating, fluid retention, disturbances in electrolytes, or gallbladder attacks and abdominal pain. For these reasons, following the diet carefully and following the gradual increase in calories after weight loss is essential.

4. Gall Bladder Disease: Any program resulting in rapid weight loss may precipitate the formation of gallstones, which could lead to cholecystitis (inflammation of your gallbladder), which is a medical urgency or emergency and could require surgery. This is typically because of the rapid weight loss, not the medications you are taking. Symptoms include right upper abdominal pain, abdominal just below your ribs, nausea, and vomiting.

5. Pancreatitis: Pancreatitis, or an infection in the bile ducts, may be caused by gallstones or the development of sludge or obstruction in the bile ducts. The symptoms of pancreatitis include pain in the left upper abdominal area, nausea, and fever. Pancreatitis may be precipitated by binge-eating or consuming a large meal after a period of dieting. Also associated with pancreatitis is long-term abuse of alcohol and the use of certain medications and increased age. Pancreatitis may require surgery and may be associated with more serious complications and death.

6. Psychiatric: There are reported cases of “hysterical or psychotic reactions” associated with the use or discontinuation of some of the drugs utilized for weight loss purposes. These reactions are extremely rare.

7. Men over 40 and post-menopausal women in general, and patients with risk factors for cardiovascular disease should have a cardiovascular evaluation before entering a medically managed weight loss program. This may include an ECG, a stress test, or other testing procedures, as per the discretion of a cardiologist. If you are over the age of 40, post-menopausal (female), smoke, have a history of high blood pressure, high cholesterol or you are diabetic, you acknowledge that you have had a cardiac evaluation and that you have been cleared medically prior to starting this weight loss program.

8. Common, but troublesome side effects may include but not be limited to dry mouth, palpitations, “speedy” feeling, headaches, sleeplessness., Rash, fever, nausea, vomiting, allergic reactions, decreased insulin sensitivity, flushing, headache, fatigue, lightheadedness, abdominal cramping, joint pain, fluid retention, and additional side effects not listed that will be discussed during your evaluation with The District Injector and/or Erica Granteed AGACNP-BC. These side effects are generally rare, and most patients tolerate treatment without an issue. (

9. Drug interactions may occur if other medications are taken. Therefore, I will check with my prescribing medical provider before starting the program if I am taking other medications.

10. Certain medical conditions may be worsened if on this program, including glaucoma, hypertension, and heart disease.

11. Pregnancy (Females Only). If you become pregnant, inform your physician immediately. Your diet must be changed promptly to avoid further weight loss because a restricted diet could be damaging for a developing fetus. You must take precautions to avoid becoming pregnant during the course of weight loss.

12. The use of medications for weight management is indicated for those patients who have a BMI of 30 or higher or a BMI of 27 or higher with other medical conditions such as high blood pressure, diabetes, or high cholesterol. Prescribing medications for patients not fitting these criteria, is considered “off label” and not “FDA approved.” Therefore, the potential risks vs. benefits may be great. For patients not fitting the BMI criteria for use of appetite suppression medication, you are acknowledging that:

  • a. You have put forth a true effort to lose weight through diet and exercise over the past 6 months and have still not achieved your weight loss goals.
  • b. That your inability to lose weight is causing significant emotional distress
  • c. You are choosing to enter this medically managed weight loss program voluntary and hold harmless The District Injector LLC and Erica Granteed AGACNP-BC for use of such medications.

13. You acknowledge that alcohol and illicit drug use is prohibited in the program. Drugs like cocaine and amphetamines when used in conjunction with appetite suppressants and other medications prescribed could cause in serious injury or death. The use of alcohol will also affect your results. (Please initial) ______

14. I understand that the physician and I will determine what my daily caloric intake will be at my initial visit.

15. I acknowledge that I understand that the amount of weight loss varies from patient to patient, and is, to a large extent dependent on each patient’s personal motivation and commitment to their diet and exercise plan. No claims as to efficacy or specific amount of weight loss is either expressed or implied. I understand the importance of routinely following up with The District Injector LLC to monitor my progress during treatment. I understand this is vital to the safety of the treatment program and certify that I will be returning monthly as prescribed.

16. I hereby authorize The District Injector LLC, Erica Granteed AGACNP-BC and additional staff of The District Injector LLC to evaluate me for admission into The District Injector LLC weight management program and treat me accordingly. I consent to obtaining blood work before treatment if deemed necessary. I certify that I am signing this under my free will and am competent to make my own medical decisions.

17. I have reviewed the mentioned risks and have determined the benefits outweigh the possible risks associated with medically managed weight loss therapy with The District Injector LLC I release any claim in court or any type of complaint that could result from treatment with The District Injector LLC, Erica Granteed AGACNP-BC and any other staff associated with The District Injector LLC and will not hold liable any provider or staff of The District Injector LLC.

18. I understand that treatment modalities utilized by The District Injector LLC might not be supported by scientific/medical literature and could be seen as experimental or based off anecdotal claims. Many medical providers, including endocrinologists, surgeons, family practice doctors, etc., might see these types of treatments as not medically necessary. I also understand that many of the medications being utilized The District Injector LLC and Erica Granteed AGACNP-BC medically managed weight loss program are considered to be used “off label” and might not be FDA approved for weight loss purposes.

By signing, I acknowledge that I have had an opportunity any concerns and the above information with The District Injector LLC and Erica Granteed AGACNP-BC either in person or by telephone conversation. I consent to the treatment being offered to me by The District Injector and Erica Granteed AGACNP-BC and I am satisfied with the explanation. I acknowledge that I have read or have had read to me the above consent and understand the information presented.

Weight Loss Program Risks and Benefits Acknowledgement

I recognize the potential risks of this treatment program, and I also understand the potential benefits of weight loss, which may include:

  • 1. Decreased risk of heart attack.
  • 2. Decreased risk of adult-onset diabetes mellitus.
  • 3. Decrease risk to developing arthritis or developing musculoskeletal conditions that are caused by excessive weight.
  • 4. Increased emotional and psychological well-being.
  • 5. Decreased risk of developing certain types of cancer.

I acknowledge that the medically managed weight loss program recommended to me by The District Injector LLC and Erica Granteed AGACNP-BC is just one of multiple strategies to reduce weight. Alternative treatment options include:

  • 1. Diet and exercise alone without medications.
  • 2. The use of other kinds of medications to achieve appetite suppression.
  • 3. Non-medical weight loss programs like Weight Watchers.
  • 4. Bariatric Surgery.

Client Obligations and Representations- Weight Loss

Any questions I have regarding this treatment have been answered to my satisfaction. I understand that I will be responsible for administering the medications prescribed to me if I do not have them administered to me in clinic. I also promise to comply with the dosages and frequency of medications prescribed to me.

I certify that I am under the regular care of a primary care provider for any other conditions I might have or am found to have. I will consult with my primary care provider or specialist regarding any other condition I might have. I understand that if I do not have a primary care provider, I will be encouraged to seek one out. I acknowledge that I am seeking care at The District Injector LLC for medically managed weight loss services The District Injector LLC offers. I acknowledge I am not wanting to establish primary care with The District Injector LLC and Erica Granteed AGACNP-BC and I am here for specialized care including weight loss therapy, diet counseling, exercising counseling etc

Regaining Weight Acknowledgement

There is a Risk of Regaining the Weight you have lost… Obesity is a chronic condition, and the majority of overweight individuals who lose weight have a tendency to regain all or some of it back over time. Factors which favor maintaining weight loss include exercise, adherence to a calorie that is low-calorie, nutritious, and full of lean proteins and vegetables, and planning a strategy for coping with weight regain before it occurs. Successful treatment may take months or even years. Utilizing medications to assist you in your weight loss goals in addition to diet and exercise could result in the weight coming back if you do not maintain eating a healthy diet and exercising. Additionally, if you have had fluctuations in your weight in the past, it may be more difficult to maintain the weight you lose.