Dr Tess of Beverly Hills/Virtual Concierge MD
Theressia L. Washington, MD, P.C.
Version 2.0 | Effective September 2, 2026
Patient name: _______________
Date of birth: _______________
State where you are physically located: _______________
Date: _______________
This is a physician-directed medical weight management program delivered by telehealth by Theressia L. Washington, MD, board certified in Family Medicine. Every visit is with the same physician.
Your care may include individualized nutrition guidance, prescription weight management medication when medically appropriate, laboratory evaluation and monitoring, behavioral and lifestyle counseling, evaluation for metabolic or hormonal contributors to weight, and ongoing dose management through active treatment and maintenance.
Booking any visit does not guarantee a prescription for any medication. Treatment is prescribed only when medically appropriate following individualized evaluation, and a different treatment may be recommended than the one you came in asking about.
This program currently uses semaglutide and tirzepatide. Other non-controlled FDA-approved options may be considered where clinically appropriate.
This program does not prescribe phentermine or any other controlled substance. If controlled substance therapy is added in the future, you would be evaluated separately and asked to sign a separate Controlled Substance Agreement before any such prescription is issued.
Semaglutide and tirzepatide are active ingredients found in several different FDA-approved products, and those products are approved for different purposes:
Product | Ingredient | FDA-approved for |
Wegovy | semaglutide | chronic weight management |
Ozempic | semaglutide | type 2 diabetes |
Zepbound | tirzepatide | chronic weight management |
Mounjaro | tirzepatide | type 2 diabetes |
If your physician prescribes a diabetes-indicated product for weight management, that is off-label prescribing — lawful, common, and based on clinical judgment, but not the FDA-approved use of that specific product. Off-label prescriptions are frequently not covered by insurance, and your cost may be substantially higher.
Your physician will tell you which product she is prescribing, whether the use is on-label or off-label, and why.
The FDA shortages that previously permitted broad compounding of semaglutide and tirzepatide have been resolved, and the FDA has proposed further restricting bulk compounding of these substances. We do not represent any compounded product as equivalent to an FDA-approved medication.
Your dose is individualized. FDA-approved dosing is the starting framework, and your physician may adjust the pace of escalation, keep you at a tolerated dose longer, or adjust your maintenance dose based on your response, side effects, and goals.
Some patients ask about microdosing — using doses below the approved range. This is off-label dosing. Lower doses have not been studied for weight management the way approved doses have, may be less effective, and are not appropriate for every patient. Where an individualized off-label approach is clinically reasonable for you, your physician will discuss the evidence, limitations, and risks before recommending it.
No specific dose or dosing regimen is guaranteed.
Meaningful weight loss may improve blood pressure, cholesterol, blood sugar and type 2 diabetes, sleep apnea, joint pain, cardiovascular risk, energy, and mobility. These benefits are not guaranteed.
Semaglutide and tirzepatide cause thyroid C-cell tumors in rodents. It is unknown whether they cause medullary thyroid carcinoma in humans. These medications are contraindicated if you or a family member has a history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2.
Nausea, vomiting, diarrhea, constipation, abdominal pain, reduced appetite, fatigue, burping, heartburn, and injection site reactions.
Pancreatitis; gallbladder disease including gallstones; acute kidney injury, usually from dehydration caused by vomiting or diarrhea; low blood sugar, particularly with insulin or a sulfonylurea; worsening of diabetic retinopathy; increased heart rate; severe gastrointestinal disease including gastroparesis and bowel obstruction; and allergic reactions.
Anesthesia warning. Delayed stomach emptying increases the risk of aspiration during sedation. Tell any surgeon, proceduralist, dentist, or anesthesiologist that you take a GLP-1 medication before any procedure.
Gallbladder disease, hair loss, fatigue, muscle loss, nutritional deficiency, electrolyte imbalance, and dehydration. Adequate protein, hydration, and resistance activity are part of your plan for this reason.
This program is generally not appropriate if you are pregnant, planning pregnancy, or breastfeeding; have a personal or family history of medullary thyroid carcinoma or MEN 2; have a history of pancreatitis; have severe gastrointestinal disease or gastroparesis; have an active or prior eating disorder; have uncontrolled cardiovascular disease or a recent cardiovascular event; have severe kidney or liver disease; or have an uncontrolled psychiatric condition. Patients under 18 and over 65 require additional evaluation.
If you can become pregnant, effective contraception is required. Tell us immediately if you become pregnant or plan to.
Obesity is a chronic condition. For most patients, the weight-lowering effect of these medications continues only while the medication is being taken.
Many patients regain a substantial portion of lost weight after stopping GLP-1 medication, and some regain all of it. Maintaining your loss may require ongoing medication, permanent changes in eating and activity, or both.
Enrollment in maintenance care reduces the risk of regain but does not prevent it and does not guarantee you will keep the weight off. No program can guarantee a permanent result.
Individual results vary and no specific amount of weight loss is guaranteed. Clinical trials of these medications have shown average total body weight reductions ranging roughly from five to twenty percent depending on the medication, dose, duration, and population studied. Your result may be greater or lesser. Some patients do not respond as expected.
Medical treatment changes measurable things — your weight, your laboratory values, your metabolic markers. It does not guarantee how you will feel.
Some patients lose significant weight and still experience fatigue, low mood, low energy, or dissatisfaction with their appearance. These symptoms have many causes, and improvement in one measure does not resolve all of them. If your weight or a laboratory value improves as expected but you do not feel the way you hoped, that does not mean treatment failed — it means further evaluation may be needed, sometimes with another clinician.
Before you begin, tell your physician what you are hoping this treatment will change for you, so she can tell you honestly whether that expectation is realistic.
☐ I understand that no specific outcome, appearance, or feeling is guaranteed, and that fees paid are for physician evaluation and management, not for a result.
You agree to take medication exactly as prescribed, never to share it, to store it safely and away from children, to keep injectable medication properly refrigerated, to disclose every medication and supplement you take, to limit alcohol, and to report side effects promptly.
Used needles and syringes must be disposed of in an FDA-cleared sharps container, available from pharmacies, medical supply companies, and online retailers. If one is not available, a heavy-duty plastic household container with a tight-fitting lid may be used as an interim measure.
Never place loose needles in household trash or recycling, and never flush them. Disposal requirements vary by state and municipality.
Your membership includes a Safe Injection & Sharps Disposal Guide. We do not supply sharps containers.
The tracker is a personal record-keeping tool to help you and your physician review your treatment together.
It is not a medical device, it does not monitor you, it is not reviewed between visits, and it does not replace clinical care. Entering a symptom in your tracker is not the same as reporting it to us. Report side effects and concerns directly through secure messaging, by phone, or by calling 911 in an emergency.
You consent to laboratory testing as clinically indicated, which may include a comprehensive metabolic panel, lipid panel, thyroid studies, and hemoglobin A1c. Laboratory costs are separate and are not included in your visit fee or membership. Declining clinically necessary monitoring may result in discontinuation of medication.
The initial visit fee is $199. Ongoing care is provided through the Medical Weight Loss Membership at $179 per month, beginning thirty days after your initial visit. Founding member pricing of $149 per month, locked for twelve months, is available to the first twenty patients.
Membership does not include medication, laboratory testing, or supplements.
Membership renews automatically each month until you cancel. You may cancel at any time, effective at the end of your current paid month, using the same method you used to enroll. We will notify you in advance of any price change. See our Subscription & Auto-Renewal Terms.
As a self-pay patient, you have the right to a Good Faith Estimate of expected charges before scheduled services.
☐ I consent to clinical progress photographs being stored in my medical record for documentation of treatment progress.
Photographs are part of your protected health information and are stored securely. You may withdraw this consent at any time.
Use of your photographs, story, or testimonial in marketing requires separate written authorization, is entirely voluntary, and has no effect on your care.
Your physician may discontinue your participation if you develop a condition making continued treatment unsafe, if you are non-adherent with appointments or required monitoring, if you misuse medication, or if you behave abusively toward staff. Services already provided are not refunded.
You may withdraw at any time. If you stop membership while taking medication, contact us so we can arrange safe continuation, a taper if appropriate, or transfer of your care. Do not stop a prescribed medication abruptly because of a billing issue.
Medical emergency — call 911. Call for severe abdominal pain, persistent vomiting with dehydration, signs of allergic reaction, or chest pain.
Mental health crisis — call or text 988.
Poison Control — 1-800-222-1222.
By signing, I acknowledge that I have read and understand this document; that my questions were answered; that I understand the risks, benefits, limitations, and alternatives, including lifestyle treatment without medication, bariatric surgery referral, or no treatment; that I have disclosed my complete medical history, medications, and supplements; that I understand weight regain is common after stopping medication; that I understand no result is guaranteed; that I understand this program does not currently prescribe controlled substances; and that I consent to participate.
Patient signature: _______________ Date: _______________
Print name: _______________
Physician signature: _______________ Date: _______________
Dr Tess of Beverly Hills/Virtual Concierge MD
9663 Santa Monica Blvd, Suite 957, Beverly Hills, CA 90210
1(310) 275-8377 | support@virtualconciergemd.com