Top Beauty Bar
Controlled Substance Agreement
Skinny Pill – Weight Loss Program (Phentermine • Topiramate • B12 • Chromium)
Purpose: The purpose of this agreement is to ensure that you, the patient, understand and agree to the conditions under which controlled substances are prescribed as part of your medical weight loss treatment using the Skinny Pill. This medication contains phentermine, which is regulated by the DEA and subject to misuse.
Patient Responsibilities: I agree to the following:
- I will take the Skinny Pill exactly as prescribed by my provider—no more, no less.
- I will not share, sell, or trade this medication with anyone under any circumstance.
- I will store my medication in a secure place to prevent theft or misuse.
- I will not request early refills. Lost or stolen prescriptions will not be replaced.
- I understand this medication may cause side effects such as dry mouth, insomnia, anxiety, or increased heart rate.
- I will inform the provider of any other medications I’m taking, including over-the-counter drugs and supplements.
- I will not use alcohol or recreational drugs while taking this medication.
- I will notify my provider if I become pregnant or plan to become pregnant.
- I understand refills require follow-up visits, including vitals and progress assessments.
- I will not obtain similar medications (e.g., other appetite suppressants or stimulants) from other providers without notifying Top Beauty Bar.
Clinic Responsibilities: Top Beauty Bar agrees to:
- Prescribe controlled substances only when medically appropriate.
- Provide clear education and instructions about usage and risks.
- Monitor patient progress through regular weight loss check-ins and vitals.
- Discontinue the prescription if it is no longer safe or medically necessary.
Grounds for Discontinuation: I understand my prescription may be stopped if I:
- Fail to follow this agreement
- Show signs of misuse, abuse, or drug-seeking behavior
- Miss appointments or fail to follow-up
- Are disrespectful to staff
- Provide false or misleading information
Allergies
Medical History Questionnaire (Please answer the following questions that pertain to you)
Please review the consent. I have read, and acknowledge these requirements. It will automatically return to the provider upon completion.
The Skinny Pill is a compounded oral capsule containing phentermine, topiramate, vitamin B12, and chromium, prescribed as part of a medically supervised weight loss program. This combination is intended to reduce appetite, enhance metabolism, increase energy, and assist with blood sugar regulation.
Medications & Mechanism:
- Phentermine: A stimulant that suppresses appetite by acting on the central nervous system.
- Topiramate: Originally used as an anticonvulsant, it has also been shown to promote fullness and reduce food cravings.
- Vitamin B12: Supports energy production and neurological health.
- Chromium: A mineral that may improve insulin sensitivity and support blood sugar balance.
Expected Benefits:
- Appetite control and reduced cravings
- Enhanced fat metabolism and energy
- Improved support for dietary and lifestyle changes
- Assistance in achieving personal weight loss goals
Potential Risks and Side Effects:
Common Effects:
- Dry mouth
- Constipation
- Insomnia or restlessness
- Tingling/numbness
- Headache or dizziness
Less Common but Serious:
- Increased blood pressure or heart rate
- Mood changes, depression, or anxiety
- Vision changes or eye pressure increase (glaucoma)
- Cognitive/memory difficulties
- Shortness of breath or chest pain
Contraindications:
I understand that I should not take this medication if:
- I am pregnant or breastfeeding
- I have a history of heart disease, uncontrolled high blood pressure, glaucoma, or severe kidney/liver disease
- I have a history of substance misuse or severe mental health conditions (unless cleared by a provider)
Program Requirements:
I understand that:
- This medication is part of a comprehensive weight loss program that includes nutrition, physical activity, and lifestyle coaching.
- I must take the medication exactly as prescribed (usually once daily in the morning).
- I will be monitored through regular check-ins, vitals, and weight tracking.
- I must report any side effects or health changes immediately.
- This medication is a controlled substance and may carry a risk of dependence if misused.
I have read and fully understand the Controlled Substance Agreement. I agree to comply with all terms as a condition of participating in the Skinny Pill weight loss program at Top Beauty Bar.
Medical Waiver
I have read, and acknowledge these requirements, of my procedure to better assist with treatment adversities that can occur if a protocol is not taken seriously. I know that this is an elective service and my questions regarding services have been answered satisfactorily I understand this procedure and accept all risks and will notify Top Beauty Bar of any changes that could put my treatment at risk.
I take full liability and responsibility for all risks, undesired outcomes, or adverse events associated with the injections and will not hold the provider of Top Beauty Bar LLC liable for any unfavorable outcome or adverse event. I release Top Beauty Bar LLC, its owner, and medical staff from liability associated with the procedure. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns. I hereby release Top Beauty Bar LLC, Tina Videtic, and staff from all liabilities associated with the indicated procedure. The procedures to be used to treat my condition have been explained to me. Any adverse reaction should be reported immediately to the office mobile at 920-678-7709.
I have read, and acknowledge these liability requirements of my procedure.
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