Informed Consent Form

The HCG diet combines extreme calorie restriction with daily shorts of a hormone produced by pregnant women called Human Chorionic Gonadotrophin (HCG). According to the Food and Drug Administration has not been demonstrated to be an effective adjunctive whether there is a better outcome with a very low-calorie diet and the HCG hormone compared to just a low-calorie diet alone.

The patient must confirm that they fit the indications for the use of the HCG diet and disclose all previous medical treatments including current treatment programs and diagnoses.

Potential Complications of the very low-calorie diet (VLCD) include high blood uric acid with gout precipitation, aggravation of gallbladder disease, or the precipitation of acute cholecystitis. Constipation of altered bowel movement, muscle cramps, dizziness, fatigue, headache, potential loss of lean body mass, alteration of menstruation in women, and hair loss. In rare circumstances a very low-calorie diet has been associated with death (often due to electrolyte or micronutrient depletions)/ Allergic reactions may occur to drugs or nutritional supplements. If you experience a skin rash, difficulty in breathing, tissue swelling or urticaria, all medications and supplements must be deconstructed. If any of the above occurs you must abandon the diet, and notify Dr. Muhammad Ali immediately. If you experience any negative side effects from the HCG diet, contact Dr. Ali directly.

If for any reason you feel you must cancel the program, there will be a $100.00 cancellation fee to cover expenses incurred to the office, in addition to a $70.00 fee to cover expenses incurred from the compounding pharmacy. The balance of payment may be refunded if necessary.

I, ________________________________________, have ready and understand all the above informed consent and all my questions have been answered. I will proceed with the very low-calorie diet (VLCD), including the adjuvant HCD diet. To proceed fill the below consent form.