Comprehensive Enrollment and Consent Form

CONTACT DETAILS

Emergency Contact

MEDICAL HISTORY

Allergies

LIFESTYLE

PROGRAM ENROLLMENT

Provider(s):

• Dr. Vivek Bansal

• Saloni Desai

• Karen Edgecomb

• Elena Procaccini

Enrolled Program:

Program Options:

✅ All-In-One Transformation – Comprehensive medical weight loss with FDA-approved medications, personalized diet

plans, and continuous support.

✅ Prime-Fit Program – Nutrition-focused, medication-free weight loss with tailored meal plans and optional protein

supplements.

✅ Med-Only Boost Program – Weekly in-clinic weight loss injections with expert medical supervision.

Acknowledgment of Risks

Physical Risks:

• Potential injuries resulting from exercise routines, including but not limited to muscle strain, joint pain, fractures, and

  cardiovascular complications.

• Adverse reactions to dietary changes, such as fatigue, dizziness, dehydration, or nutrient deficiencies.

• Risks associated with weight loss procedures or treatments, including potential complications from injections or

  supplements.

Medical Risks:

• The possibility of worsening or aggravating pre-existing medical conditions such as diabetes, hypertension, or

  cardiovascular disease.

• Unexpected side effects or complications arising from prescribed medications, dietary changes, or exercise programs.

• The necessity for ongoing medical monitoring and potential adjustments to treatment plans to mitigate risks.

Psychological Risks:

• Emotional distress, anxiety, or depression due to changes in body image, lifestyle modifications, or weight management challenges.

• Increased stress or frustration in cases of slower-than-expected progress or plateauing weight loss.

• Potential impact on self-esteem and mental health, necessitating psychological support or counseling.

Property Risks:

• The risk of loss, theft, or damage to personal belongings while on the premises of EnLyv Me facilities.

• Limited liability of EnLyv Me for any personal items lost, stolen, or damaged within clinic premises.

Financial Responsibility

I understand and agree to the following financial terms associated with my enrollment in the EnLyv Me program:

Self-Pay Program:

• I acknowledge that the EnLyv Me program operates on a self-pay basis, and no claims will be submitted to insuranceproviders for reimbursement.

• I understand that I am solely responsible for all program fees and associated costs.

Non-Refundable Fees:

• I acknowledge that all program fees, including but not limited to consultations, medications, and treatments, are non-

  refundable.

• In the event that I discontinue participation in the program, I will not be eligible for a refund or credit for unused

  services.

Payment Terms:

• Full program fees must be paid at the time of enrollment unless a formal payment arrangement has been made in

  writing.

• Any additional treatments or services requested beyond the scope of the initial program agreement must be paid for

  separately.

Returned Payments

• A $35 fee will be charged for any returned checks or declined payments due to insufficient funds or payment processing issues.

• I agree to provide updated payment information if my initial payment method becomes invalid or is declined.

Missed Appointments and Cancellations:

• A $50 fee will be applied for appointments missed or canceled without at least 48 hours' advance notice.

• Repeated absences or failure to adhere to scheduled appointments may result in temporary suspension or termination

  from the program.

• Rescheduling of appointments is subject to provider availability and may require additional fees.

Consent for Compounded Weight Loss Medication

acknowledge that I have requested the use of compounded weight loss medication(s) as part of my treatment plan. I understand that my healthcare provider is not endorsing, prescribing, or forwarding these medications . I confirm that I have independently chosen to pursue treatment with compounded medications and take full responsibility for

their use. I acknowledge that compounded medications are not FDA-approved, and their safety, efficacy, and long-term effects may not be well-documented.

Medication Information

Acknowledgment of Risks and Responsibilities

I understand and accept that:

1. Use of Compounded Medications is Patient-Requested

• I have independently requested the use of compounded medication(s) and understand that my provider is not

  prescribing, supplying, or assuming responsibility for these medications.

• My provider has informed me of alternative FDA-approved treatments available for weight loss.

2. Compounded Medications Are Not FDA-Approved

• These medications are custom-made by compounding pharmacies and do not undergo FDA review for safety,

  efficacy, or quality control.

• The potency and purity of compounded medications may vary, and there is a risk of contamination or inconsistent

  formulation.

3. Potential Risks and Side Effects

Compounded weight loss medications may cause side effects, including but not limited to:

• Common Side Effects: Nausea, vomiting, diarrhea, constipation, bloating, headaches, dizziness, or fatigue.

• Metabolic Risks: Low blood sugar (especially if combined with diabetes medications), dehydration, or electrolyte

  imbalances.

• Serious Risks: Pancreatitis, gallbladder disease, thyroid tumors, kidney or liver dysfunction, severe allergic reactions, or

  cardiovascular complications.

• Long-Term Safety Unknown: There is limited long-term data on the safety and effectiveness of compounded versions

  of these medications.

4. Pregnancy and Reproductive Considerations

• I understand that weight loss medications should not be used during pregnancy or while trying to conceive.

• I agree to immediately notify my provider if I become pregnant or plan to conceive while using these medications.

5. No Guarantees of Effectiveness

• Weight loss outcomes vary from person to person, and there is no guarantee of success.

• Compounded medications may not work as expected due to variability in formulation and individual response.

6. My Responsibilities

By signing below, I confirm that:

☑ I have independently requested the use of compounded medication(s).

☑ I understand that my provider is not prescribing, endorsing, or forwarding these medications.

☑ I acknowledge the risks associated with compounded medications.

☑ I take full responsibility for obtaining, using, and monitoring my response to these medications.

☑ I will promptly report any adverse effects to my provider.

☑ I understand that my provider recommends regular follow-ups for health monitoring.

Legal Waivers and Acknowledgments

By signing this agreement, I acknowledge and accept the following terms:

1. Financial Responsibility

I accept full financial responsibility for all costs associated with the program, including:

• Medical consultations, follow-up visits, and evaluations.

• Prescription medications, supplements, injections, and related treatments.

• Laboratory tests, screenings, or additional diagnostic services.

• Any specialized treatments recommended by my provider.

I understand that all payments are non-refundable, regardless of treatment outcomes.

I agree to adhere to EnLyv Me’s cancellation and rescheduling policies and accept any applicable fees for missed

appointments.

I acknowledge that failure to pay outstanding balances may result in the discontinuation of my participation in the

program.

2. Commitment & Compliance

• I understand that my results depend on my adherence to the program, including following dietary guidelines,

  prescribed medications, and lifestyle recommendations.

• I commit to attending scheduled follow-ups, providing honest and complete health information, and notifying my

  provider of any medical changes.

• I will not modify or discontinue prescribed treatments without consulting my provider.

3. Liability Waiver

I acknowledge that while this program is medically supervised, all treatments carry inherent risks, including but not

limited to:

• Side effects from medications such as nausea, fatigue, or allergic reactions.

• Changes in metabolic function, blood pressure, or other health markers.

• Weight fluctuations or challenges in achieving expected results.

I voluntarily assume all risks associated with treatment and release EnLyv Me, its medical team, and affiliates from liability, except in cases of proven medical negligence.

I confirm that I have been informed of the benefits, risks, and alternatives, and I have had the opportunity to ask questions before consenting to treatment.

4. Treatment Discontinuation

I understand that my provider reserves the right to discontinue treatmentif:

• Continuing care poses a health risk.

• I fail to comply with medical recommendations or program guidelines.

• I provide false or incomplete medical information.

• I engage in inappropriate behavior towards EnLyv Me staff or disrupt program operations.

I acknowledge that if my participation is terminated, I will not be eligible for refunds on prepaid services, medications,

or products.

5. Medical Disclosures & Informed Consent

• I confirm that I have disclosed all relevant medical conditions, allergies, and current medications.

• I understand that certain conditions (e.g., pregnancy, severe cardiovascular disease, uncontrolled diabetes) may make

  me ineligible for specific treatments.

• If I experience any adverse reactions or concerns, I will notify my provider immediately.

• I acknowledge that my treatment plan may be adjusted based on my progress, lab results, or medical needs.

By signing below, I confirm that I have read, understood, and voluntarily agree to the terms outlined in this document.

Agreement and Consent

Contact Information

Phone: (908) 895-8700

Email: contact@enlyv.com

Clinic Locations

• Flemington:

  5 Walter E Foran Blvd, Suite 4000, Flemington, NJ 08822

• Bridgewater Township:

  19 Monroe St, Bridgewater Township, NJ 08807

• Edison:

  2 State Route 27, Levinson Plaza, Suite 508, Edison, NJ 08820