Semaglutide Intake Form

Please take a minute to fill in the following information.

Personal Information First Name: Last Name: Birth Date: Emergency Contact with Phone Number: Email: Phone Number: Address:

Are you under a doctor’s care at the present time?

Yes No

If yes, please list the Dr's name and contact information:

Health Conditions

Do you currently have or have you had any of the following health conditions? (Select all that apply):

Please list all surgeries and other hospitalizations (Reason, Year, Hospital): Do you have any allergies? If so, please list: Are you currently taking any medications or supplements? If so, please list: Do you have any allergies to medication? If so, please list:

Exercise Habits

Please select the option that best describes your exercise habits:

Inactivity - no exercise activity with a sit-down job
Light Activity - no organized physical activity
Moderate Activity - occasionally involved in physical activity
Heavy Activity - heavy construction, lifting, stair climbing or regular physical activity 3x/week
Vigorous Activity - persistent physical exercise for at least 60 minutes 4x/week

Dietary and Lifestyle

Are you currently dieting now?

Yes No

How many meals do you eat in an average day?

What is your daily salt intake?

Low Moderate High

What is your daily caffeine intake?

Low Moderate High

How many cups/cans per day do you drink? What types of caffeine do you drink:

Coffee Tea Soda None

Do you drink alcohol?

Yes No

If yes, how many times per week?

Do you smoke?

Yes No

If yes, what types of smoking do you engage in:

Cigarettes Other tobacco products

If yes to cigarettes, how many packs per day do you smoke?

*Women Only* - Are you currently pregnant, trying to get pregnant, or breastfeeding?

Yes No

Weight Loss Goals and History What is your main reason you want to lose weight? At what age did you begin gaining excess weight? (Provide details if possible) What is the main cause of your weight problems? What other weight loss programs and previous diets have you tried? Do you have any food allergies or foods you avoid? What foods do you crave most often? Please describe your snack habits:

Do you eat more when you are stressed?

Yes No

What do you feel are your obstacle(s) to successful weight loss?

Consent and Certification

I certify that the preceding medical, medication, and personal history statements are true and correct. I am aware that it is my responsibility to inform the service provider or other health professional of my current medical health conditions and to update this history. A current medical history is essential for the service provider to execute appropriate treatment procedures. I have read and understand the above medical history questionnaire. I acknowledge that all answers have been recorded truthfully and I will not hold any staff member personally responsible for any errors or omissions that I have made in the completion of this form.

Print Your Name:

The purpose of this informed consent form is to provide written information regarding the risks, benefits, and alternatives of the semaglutide injections. This material serves as a supplement to the discussion you have with your service provider. It is important that you fully understand this information, so please read this document thoroughly and select "Yes" in the appropriate dropdowns. If you have any questions regarding the procedure, ask your service provider before signing the consent form.

THE TREATMENT

Semaglutide is a weight loss drug that has recently had extensive clinical studies to prove its safety and efficacy. It is an injectable medication that increases your satiety and reduces your food intake. It works by mimicking the effects of insulin in your body which helps slow down the emptying of your stomach and signaling your brain that your stomach is full, as a result you feel full for longer periods of time and eat less. This is not a quick fix though; you still have to make smart food choices and get your body moving every day. Semaglutide is a once-a-week injection that can easily fit into your busy schedule. The benefits help reduce hunger pangs and help you lose weight faster when you combine the injections with a low-calorie diet. It is best to take medication at night.

Have you read the above treatment statement?

RISKS AND COMPLICATIONS

Before undergoing this procedure, understanding the risks are essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Semaglutide may cause serious side effects, including: inflammation of your pancreas (pancreatitis). Stop using Semaglutide and call your service provider if you have severe pain in your stomach area (abdomen) that will not go away, with or without vomiting. You may feel the pain from your abdomen to your back. Semaglutide may cause gallbladder problems, including gallstones. Call your service provider if you have symptoms such as pain in your upper stomach (abdomen), fever, yellowing of the skin or eyes (jaundice), or clay-colored stools. Increased risk of low blood sugar (hypoglycemia) in patients with type 2 diabetes, especially those who also take medicines for type 2 diabetes such as sulfonylureas or insulin. This can be both a serious and common side effect. Talk to your service provider about how to recognize and treat low blood sugar and check your blood sugar before you start and while you take Semaglutide. Signs and symptoms of low blood sugar may include dizziness or light-headedness, blurred vision, anxiety, irritability or mood changes, sweating, slurred speech, hunger, confusion or drowsiness, shakiness, weakness, headache, fast heartbeat or feeling jittery. In people who have kidney problems, diarrhea, nausea, and vomiting may cause a loss of fluids (dehydration) which may cause kidney problems to get worse. It is important for you to drink fluids to help reduce your chance of dehydration. Stop using Semaglutide and get medical help right away, if you have any symptoms of a serious allergic reaction, including swelling of your face, lips, tongue, or throat; problems breathing or swallowing; severe rash or itching; fainting or feeling dizzy; or very rapid heartbeat. Tell your service provider if you have changes in vision during treatment. Semaglutide can increase your heart rate while you are at rest. Tell your service provider if you feel your heart racing or pounding in your chest and it lasts for several minutes. You should pay attention to any mental changes, especially sudden changes in your mood, behaviors, thoughts, or feelings. Call your service provider right away if you have any mental changes that are new, worse, or worry you.

The most common side effects of Semaglutide may include: nausea, diarrhea, vomiting, constipation, stomach (abdomen) pain, headache, tiredness (fatigue), upset stomach, dizziness, feeling bloated, belching, gas, stomach flu, and heartburn.

Have you read the above risks and complications statement?

ALTERNATIVE PROCEDURE

Alternatives to the procedure and options that I have volunteered for have been fully explained to me.

Have you read the above alternative procedure statement?

PHOTO USAGE

I give permission to take before and after photographs of my treatment to be used to monitor my treatment, training purposes, social media usage, and advertising.

RIGHT TO DISCONTINUE TREATMENT

I understand that I have the right to discontinue treatment at any time.

Have you read the above right to discontinue treatment statement?

RESULTS

Typically, it takes about 2 weeks for Semaglutide to start working in the body. Some people begin to see results within the first eight weeks, but most begin to see results within twelve weeks.

I understand this is an elective procedure and I hereby voluntarily consent to treatment with Semaglutide injections for weight loss. The procedure has been fully explained to me. I also understand that any treatment performed is between me and the service provider who is treating me and I will direct all post-operative questions or concerns to the treating clinician. I have read the above and understand it. My questions have been answered satisfactorily.

I accept the risks and complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history I will notify the service provider who treated me immediately. I also state that I read and write in English.

Your Signature: