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Hayes Clinic & Spa

Patient Information & Medical History

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MIC LIPOSLIM Consent Form

Injection Components: Thiamine HCl 50 mg Riboflavin-5-Phosphate 10 mg Dexpanthenol 5 mg Methylcobalmin 1mg (1000 mcg) Vitamin C 50mg Choline Chloride 25 mg Carnitine 50 mg Methionine 12.5 mg Niacinamide 15 mg Pyridoxine HCl 5 mg Methyl-Folate 1 mg (1000 mcg) Inositol 25 mg Crhomium Picolinate .1mg Lidocaine 5 mg **The main ingredients in Hayes Clinic & Spa’s MIC LIPOSLIM injection include Choline Chloride (amino acids), inositol (a vitamin-type nutrient), and vitamin C.**

Please check to verify:

I’m not allergic to eggs.

Please check to verify:

I’m not allergic to any of the following: Benzyl alocohol, sulfur, lidocaine, or cobalt.

Please check to to attest:

I do not have Chronic Liver Disease, Renal Failure, Leber’s Hereditary Optic Neuropathy, or Megaloblastic Anemia

If you have any of these diseases or ailments, there could be significant contraindications resulting in atrophy, gout, and fatal hypokalemia.

I have requested Hayes Clinic & Spa and their staff to provide me with MIC LIPOSLIM injection. While all components of the injection have no major side effects, doses must be taken at regular intervals and must be combined with a logical, recognized weight-loss program and other health benefits. As a "MIC LIPOSLIM" injection, Hayes Clinic & Spa's MIC LIPOSLIM is intended to enhance fat metabolism while transporting and enhancing energy to support increased activity levels. I understand that any medical treatment may involve risks, as well as the proposed benefits. I have read and understand the ingredients of the products being administered to me, and I consent to treatment. My digital signature hereby affirms that I have fully and completely read, understand, and agree to this waiver and release and all contents thereof.

DISCLAIMER: By typing your name above, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

Notice of Privacy Practices:

Hayes Clinic 520 N Collegiate Drive Paris, TX 75460 License Number: H 9983 Effective Date: April 1, 2003

As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPPA). Our office strives to protect your privacy in all phases of care we provide for you. Your records can only be released to another party if you have given our office written permission for us to do so. This protection covers the release of information to pharmacies, other doctors, and insurance companies. We must have your written permission on file before we can release your information. On file in our office, we have a complete copy of the NOTICE OF PRIVACY PRACTICES/HIPAA FORMS, and you are entitled to a copy of this notice upon request. Please contact our staff if you would like a copy. By signing below, you show that you have been advised of our privacy practices.

DISCLAIMER: By typing your name above, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

ID Upload

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Please upload a clear photo of your state issued ID or Driver’s License.