QUINTESSENCE H&W

Semaglutide/ Tirzepatide injections are in a class of medications called incretin mimetics. They both work 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. Both injections work by slowing the movement of food through the stomach and may decrease appetite and cause weight loss.

 Tirzepatide is a synthetic derivative of gastric inhibitory polypeptide (GIP) that has simultaneous glucagon-like peptide-1 (GLP-1) functionality as well. This combination allows Tirzepatide to lower blood glucose levels, increase insulin sensitivity, boost feelings of satiety, and accelerate weight loss. Tirzepatide was developed to fight type 2 diabetes, but has additionally been shown to protect the cardiovascular system and act as a potent weight loss agent

How should these medications be used?

Each medication comes as a solution (liquid) in a prefilled syringe 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 administer the medication 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 either Semaglutide or Tirzepatide injections 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 initially and will increase your dose every 4 weeks. Patients may elect to stay a certain weekly dose if they feel their current dosing is effective and they are achieving their desired results

Semaglutide/Tirzepatide injections 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.

Tirzepatide

The medication mimics the action of two hormones involved in blood sugar control: Glucagon-like peptide-1 (GLP-1) and Glucose-dependent insulinotropic polypeptide (GIP), a hormone that results in decreased appetite. Tirzepatide also impacts food intake and increases energy expenditure, which further results in weight reductions.

 

STATEMENT OF INFORMED CONSENT FOR USE OF SEMAGLUTIDE AND/OR TIRZEPATIDE

I have sought the medical services of Elevation Medical Weight Loss due to my excess weight or obesity. I have discussed the limited success I have had in losing weight by diet and exercise alone. I understand I will be prescribed medications. These medications may include semaglutide or tirzepatide. I understand I will need to change my diet, exercise frequency and behaviors to aid in my long-term weight reduction efforts. I understand that the management of my weight will require a lifelong effort, no matter what method of weight reduction I choose. I understand that no drug can provide a quick fix for the problem of weight reduction and management. Prior to my treatment, I have fully disclosed any medical conditions or diseases such as pregnancy, trying to get pregnant, breastfeeding, history of gallbladder disease, diabetes, autoimmune diseases, HIV, heart disease, liver disease, kidney disease, uncontrolled high blood pressure, seizure disorders, blood disorders, anemia, thalassemia, hemophilia, etc), emphysema or asthma, any history of stroke or cancer, multiple endocrine neoplasia Type II, or medullary thyroid carcinoma. These contraindications have been fully discussed with me. If I fail to disclose any medical condition that I have, I release the physician and facility from any liability associated with this treatment. I understand that one who is overweight or obese has a heightened risk of suffering from high blood pressure, heart disease, diabetes, heart attack, stroke and arthritis (particularly involving the hips, knees and feet) Depression is more common in obese persons than in others. I understand that the risks of incurring these conditions tend to increase as one’s obesity increases. I understand that semaglutide is 94% similar to natural human glucagon-like peptide 1 (GLP-1). Tirzepatide is the first dual GIP/GLP-1 receptor co-agonist. Both compounds acts as a physiological regulator of appetite and thereby reducing food intake by reducing feelings of hunger and increasing feelings of fullness/satiety. For long term success the treatment needs to be combined with lifestyle changes including nutritional, exercise and behavioral habits. I understand that my use of semaglutide/tirzepatide may expose me to the risks of various conditions, including but not necessarily limited to low blood sugar (glucose ≤70 mg/dL), fast heart rate, sweating, shakiness, intense hunger, or confusion, nervousness, overstimulation, restlessness, dizziness, insomnia (inability to sleep), euphoria (sense of well-being), dysphoria (sense of unhappiness or depression), tremor, headache, dry mouth, diarrhea, constipation, other gastrointestinal disturbance, medication allergies, impotence, or changes in libido (sex drive). I further understand that my use of semaglutide/tirzepatide may expose me to the less probable but more serious risk of potential pancreatitis, cholelithiasis and cholecystitis (gallstone and gallbladder disease), thyroid disease, heart rate, and dehydration. I am encouraged to ask questions as concerns may arise. I should promptly bring any questions I have to the attention of a qualified provider. I understand that if I begin to experience any unusual or unexpected symptoms at any time after I begin using semaglutide/tirzepatide, I should immediately contact my doctor. Unusual symptoms may include, but are not limited to, shortness of breath, edema (swelling of hands, legs or feet, heart palpitations or tachycardia (rapid heartbeat), nervousness, restlessness, insomnia, tremor, rapid breathing or respiration, or inability to tolerate exercise or activity. I understand that I may seek help from another qualified physician or go to a hospital emergency room. I understand that I should use semaglutide/tirzepatide in the manner prescribed by the doctor and not provide this medication to any other person. I understand that I should not increase my dosage of semaglutide/tirzepatide or use it with any other drug or substance without the recommendation of my doctor . Serious injury or death can result from improper use of medications and/or the illegal transfer of medications to another individual. I understand that I may decline to begin treatment using semaglutide/tirzepatide. I also understand that I may stop using semaglutide/tirzepatide at any time in the future, but should notify my doctor before doing so. I recognize that it is safer to diet alone. I am requesting medication to help control my appetite. I assume responsibility for taking my diet pills and waive Elevation Medical Weight Loss of any liability. My health has been good and I will advise Elevation Medical Weight Loss should my health change. I understand that I may stop this program at any time. While adverse side effects or complications are not expected, in the event an illness does occur, I understand that I need to contact Elevation Medical Weight Loss, inc. immediately. If I experience an emergency situation, I understand that I need to go to the emergency room. I understand the risks set forth above to my satisfaction. I have had an opportunity to ask questions I have concerning these and any other potential risks. I am encouraged to ask questions as concerns may arise. I should promptly bring any questions I have to the attention of a qualified physician. I have read and understand this consent form. I have had the opportunity to ask questions concerning this consent form and the medications to be prescribed for me. Any questions I have asked have been answered to my satisfaction. I understand that I should not sign this consent form unless I understand its contents, as well as the risks and benefits associated with the treatment proposed by Elevation Medical Weight Loss. I agree to release the physician and facility from any liability associated with semaglutide/tirzepatide treatment. In the event a dispute arises over the outcome of this treatment, I consent solely to arbitration as a legal means of settlement. Payment is due at the time services are rendered. According to FDA Policy Sec. 460.300, I acknowledge that I cannot return or receive refunds for medications and/or injections once the medications/injections leave the office regardless of effectiveness or possible adverse reactions.

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/ Weight Loss Injections
• 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.

 

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, there will be no refunds.  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 minimum 3 months, after which the recurring payments will transition to month to month. Recurring payments will continue each month unless patient submits a 30 day written notice to cancel or stop services to Quintessence Health and Wellness. 

The structure is as followed:

Semaglutide: (with or without Vitamin b12)

$350 Per Month - Monthly Pre Filled Syringes Delivered to your door, or you can come into the office to pick them up at our office.

Trizepatide: (with or without Vitamin b12)

$450 Per Month - Monthly Pre Filled Syringes delivered to your door, or you can come into the office to pick them up at our office.

* Any medications being shipped to patients are subject to a shipping fee which the patient will be responisble to pay to the clinic.