New Customer

Weight Loss Management Consent Form

RISK AND COMPLICATIONS

It has been explained to me that there are certain inherent and potential risks and side effects of taking Phentermine. Additionally, I understand that although phentermine is one of the most prescribed weight-loss medications, it isn't a good option if you have heart disease, high blood pressure, an overactive thyroid gland or glaucoma. It also isn't for women who are pregnant, may become pregnant or are breast-feeding.

Furthermore, I acknowledge that I have carefully read this waiver and release and fully understand that it is a release of liability. I expressly agree without prejudice to release and discharge Simpli Pretty Cosmetics, LLC and all its affiliates from all claims or causes of action and I agree to voluntarily give up or waive any right to bring a legal action against Simpli Pretty Cosmetics, LLC for personal injury.

PREGNANCY, ALLERGIES

By clicking ‘Yes’, you are confirming that you have read, agreed to and understood that YOU are aware that you are NOT pregnant, have any significant medical diseases, or have any severe allergies.

PAYMENT

I understand that this weight loss management with phentermine service is voluntary on my behalf, and that payment is my responsibility. I hereby voluntarily consent to treatment with phentermine to aid in my goal to manage my weight gain.
The program has been explained to me. I have read the above and understand it. My questions have been answered satisfactorily. I acknowledge and accept the risks associated with the program and take full responsibility for my involvement.

By clicking ‘Yes’, you are confirming that you have read, agreed to and understood the consent form for the Weight Loss Management Consent Form.

Binge Eating Disorder Questionnaire

The following questions ask about your eating patterns and behaviors within the last three months. For each question, choose the answer that best applies to you.

Weight Loss Medical Form

ALLERGIES:

Health and Lifestyle

Disclosure Agreement

I, hereby release Simpli Pretty Cosmetics and its providers from any liability associated with the services provided to me. I understand and agree that I am voluntarily engaging in these services and assume all risks involved.

I acknowledge that Simpli Pretty Cosmetics and its providers are not responsible for any adverse reactions, injuries, or damages that may occur as a result of these services. I release Simpli Pretty Cosmetics and its providers from any claims, demands, and damages, including but not limited to those arising from negligence.

I have read and understood Simpli Pretty Cosmetics' Payment Policy Notice. I agree that all services/products and treatments rendered are non-refundable, full payments are mandatory upon request, and in case my health insurance/or any other payment method doesn't cover the expenses, I will be responsible for settling any outstanding payments.

My signature on this release form grants Simpli Pretty Cosmetics and its providers permission to retain it in my records for current and future services, products, and treatments.

I have read and understood this consent and release of liability form and agree to its terms willingly.