QUINTESSENCE H&W

Semaglutide injection is in a class of medications called incretin mimetics. It works by helping the pancreas to release the right amount of insulin when blood sugar levels are high. Insulin helps move sugar from the blood into other body tissues where it is used for energy. Semaglutide injection also works by slowing the movement of food through the stomach and may decrease appetite and cause weight loss.

 

How should this medicine be used?
Semaglutide injection comes as a solution (liquid) in a prefilled dosing pen to inject subcutaneously (under the skin). It is usually injected once a week without regard to meals. Use semaglutide injection on the same day each week at any time of day. You may change the day of the week that you use semaglutide as long as it has been 2 or more days (48 or more hours) since you used your last dose. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Use semaglutide injection exactly as directed. Do not use more or less of it or use it more often than prescribed by your doctor.

Your doctor will probably start you on a low dose of semaglutide injection and increase your dose after 4 weeks. Your doctor may increase your dose again after another 4 weeks based on your body's response to the medication.

Semaglutide injection helps to control diabetes and weight loss, but it is not a cure. Continue to use semaglutide injection even if you feel well. Do not stop using semaglutide injection without talking to your doctor.

SemaGlutide

Semaglutide, sold under the brand name Ozempic among others, is an antidiabetic medication used for the treatment of type 2 diabetes and long-term weight management. Semaglutide acts like human glucagon-like peptide-1 (GLP-1) in that it increases insulin secretion, thereby increasing sugar metabolism. It is distributed as a metered subcutaneous injection.

QUINTESSENCE HEALTH & WELLNESS
RELEASE OF LIABILITY WAIVER

This waiver is to be signed by adults participating in services and/or treatments

Acknowledgment and Assumption of Risk
I am aware of the dangers and the risks to my person and property involved in participating in any of the
following services

• Medical Weight Loss
• IV Ketamine Infusion
• Lipo-Sculpting Non-Invasive Body Contouring
• Testosterone/ Hormone Replacement Therapy
• Medical Cannabis Card/ Letter
• Botox/ Dermal Fillers
• IV Vitamin/ IV Hydration Therapy

I agree to fully comply with the applicable laws, policies, rules and regulations, and any supervisor’s and/or Qualified Medical Provider's instructions regarding my participation in this program. 

I understand that the State of Utah (State) does not insure participants in the above-described activity, that any coverage would be through personal insurance, and the State has no responsibility or liability for injury resulting from this activity.

I voluntarily elect to participate in this program, and I hereby agree to accept and assume any and all risks of property
damage, personal injury, or death.

Waiver of Liability and Indemnification:

In consideration for being allowed to voluntarily participate in the above-referenced event, on behalf of myself, my personal representatives, heirs, next of kin, successors and assigns, I forever:

a. Waive, release, and discharge Quintessence H&W, and its agencies, officers, and employees from any and all negligence and liability for any of my personal injury, property damages, death, disability, property claims of any nature which may hereafter accrue to me, and my estate as a direct or indirect result of my participation in the above referenced activity or event; and

b. Defend, indemnify, and hold harmless Quintessence H&W, its agencies, officers and employees, from and against any and all claims of any nature including all costs, expenses and attorneys’ fees, which in any manner result from participant’s actions during this activity or event.  I hereby give consent to receive medical treatments/services from Quintessence H&W which may be deemed advisable in the event of injury, accident or illness during this activity or event. This release, indemnification, and waiver shall be construed broadly to provide a release, indemnification, and waiver to the maximum extent permissible under applicable law. I, the undersigned participant, affirm that I am at least 18 years of age and am freely signing this
agreement.

c. I have read this form and fully understand that by signing this form I am giving up legal rights and/or remedies which may otherwise be available to me regarding any losses I may sustain as a result of my participation. I agree that if any portion is held invalid, the remainder will continue in full legal force and effect.

Informed Consent for Weight Management Program

Clients Voluntary Enrollment

I am voluntarily enrolling in the Quintessence H&W Weight Loss Program. I hereby authorize Quintessence Health and Wellness LLC and its staff to provide support for me to achieve the goals of weight loss and weight maintenance.   Such support may include but is not limited to obtaining a complete medical and weight history, a physical examination, appropriate   laboratory screening, follow-up visits as per our office’s recommendations, direct phone calls, psychological therapy, nutritional counseling and vitamin supplementation.

Program Purpose and Risks of Obesity

The purpose of enrollment in the program is for the benefit of my overall health and to lose weight. Obesity and being overweight increases my risk for developing heart disease, diabetes, stroke, cancer, and many other diseases.   It also reduces my overall life expectancy.   I recognize these current risks to my health as unacceptable and wish to aggressively address my weight by enrolling in this program.

No Guarantees

I understand that no guarantee or representation has been made or given to me by anyone as to the results or outcomes of this weight management program.   I understand that a major part of the success of the program will depend upon my own personal efforts in following the advice and recommendations I have received as a program participant.

Risks of the Program

I understand that there are some small risks to me in choosing to enroll in this program.  These risks include but are not limited to the following:

1)   Rapid weight loss

2)   I may feel a slight burn during injections,  it quickly subsides. 

3)   I understand that regular follow-up calls with your health coach and supervising doctor allows for early detection and management of these possible problems.

General Comments

 I understand that in consenting for treatment I agree to pay in full for all visits and charges at the time of each visit.  I understand that there are no refunds given at any time for any reason.

Insurance Billing

Health insurance companies do not pay for programs such as this one.  I understand that I am personally responsible for payment of all services rendered at this facility for weight management.   We do not bill any insurance company for any service rendered at this clinic.   We will provide you with a receipt that includes the diagnosis code and charges recorded if you wish to attempt to obtain reimbursement for services rendered on your own including HSA and VEBA accounts.

 

SHARE YOUR WEIGHT LOSS PROGRAM SUCCESS STORY!

You’ve been a Quintessence Health & Wellness Weight Loss Program client and
you’ve seen first hand how effective it can be! Help us share your story with the
world! Has the Quintessence Weight Loss Program dropped off your weight and
given you back the ability to enjoy life? Has it helped you avoid surgery and or
improved the quality of your life? Whatever your story has been, please share how
this program has changed your life!

Please fill out the short questionnaire below. When you are finished, please read and sign the release on the next page to give us permission to use your testimonial.  Then simply scan and email your testimonial to Quintessencehw@gmail.com or mail it to our head office.

 CLIENT TESTIMONIAL RELEASE CONSENT

Purpose of Consent: By signing this form, you are herby the office consenting to
allow , to use and disclose the information you provided in your video/written
client testimonial and acknowledge that your testimonial may be distributed to the
public.

Right to Revoke: You have the right to revoke this release at any time by providing
written notice of your revocation and submitting it to the contact person listed
below.

1. How has the Weight Loss Program improved the quality of your life?
Ex: Weight lost, inches lost, blood panel improvements, moods & energy
improved, etc.
2. What would you say to someone who wanted to start our Weight Loss
Program?
3. What has pleased you the most upon completing our Weight Loss
Program?

CONSENT TO RELEASE

Written Testimonial    Form Before and After Photos     Video Testimonial
I hereby authorize Quintessence Health and Wellness to use my testimonial and/or
before and after photos and/or my video testimonial along with any information
contained herein its public relations efforts.

I understand and approve the disclosure of testimonial and program success
information to the media and other individuals and entities that may be involved in
the public relation efforts of Quintessence Health & Wellness LLC.
I understand and acknowledge that the media may be interested in telling my story, and I am willing to cooperate and participate in media interviews as they arise.

I understand that I am providing the testimonial and program success information
to Quintessence Health & Wellness LLC and that private information is protected by
client-doctor-health coach privacy, including private health information in my
health records, the confidentiality of which may be protected by federal and state statutes and regulations, including the Health Insurance Portability and
Accountability Act (HIPPA).

I waive the right of prior approval and hereby release Quintessence Health &
Wellness LLC from any and all claim for damages of any kind based on the use of mytestimonial, before/after photos or my video testimonial and information in the
testimonial. By signing below, I agree and acknowledge that I have read and
understood the above release and agree to all terms described. I am of legal age and freely sign this Consent to Release my Client Testimonial.

 

 

FINANCIAL AGREEMENT

Congratulations and welcome to Quintessence H&W, we are excited you are taking positive steps, and our commitment is in assisting you toward transforming your health with our program.  We are very selective in who we decide to coach, and only accept health participants who are committed to the lifestyle changes and recommended protocols needed for health and healing.   

It is illegal and highly unethical for any consultant to guarantee results for any health care condition, however, we can speak from experience, and the success rate we have witnessed has been tremendous. We are not treating your allopathic conditions, such as diabetes, heart disease or hypothyroid etc.; rather, we are supporting metabolic and functional imbalances as they are identified. We can assure you that we will do everything in our power to lead you to a favorable outcome.

Upon receipt of payment in this new Health Coaching Program, there will be no refund.  All payments are Final. The reason we have a no refund policy is because your program is built around a custom plan and intellectual property, which you receive immediately. The value of your program is built around this plan and intellectual property.

If monthly payments are being made and care is discontinued after your first initial paid evaluation appointment, there will be no refunds.  Payments will be made until balance is paid off.

Your consistency with our recommendations is very important to the success of this program; therefore, any support within this program must be utilized within the agreed 9 weeks of inception of your financial agreement.  Any communication or support not used during this time will be considered expired and invalid for use. Please note that the follow up appointments are at no cost and therefore are not included in the case fee.  The ongoing support, which is at no cost to you, is designed to help and guide in the implementation of those protocols.

Any controversy or claim arising out of or relating to this contract, or the breach thereof, shall be settled by arbitration administered by the American Arbitration Association under its Commercial Arbitration Rules. The place of arbitration shall be Salt Lake City, Utah. Utah law shall apply. Judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. The decision of the arbitration will be legally binding. Either party may take no other method of legal action.

The appointments are either in person, via phone or Skype, and are not intended to treat disease, but to coach health participants back to a healthy life style. I understand that New Wave Healthcare conducts business in a virtual space, which means we support our clients in person or telephone.  

We ask you to commit to 3 months. During this year the pay structure is as followed:

In state Patients:

$500 Per Month - Monthly Per Filled Syringes Delivered to your door, or you can come into the office to pick them up or have a nurse inject you.

Out of State Patient:

$600 Per Month - Monthly Per Filled Syringes delivered to your door and Video calls with the nurse or our weight loss specialist.