Informed Consent and Medical Intake*
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    live 18-5-2023
  • Semaglutide/Vitamin B Medical Weightloss Program

    *This questionnaire is to help determine if this treatment is appropriate for medical weightloss using Semaglutide & Vitamin B supplement
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  • **** If you have any of the above medical conditions you may not be medically cleared for this medical weightloss program. Please discuss this with your nurse before continuing this form.******

  • Clear
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  • Medical Intake History

    Wieghtloss program
  • Format: (000) 000-0000.
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  • Format: (000) 000-0000.
  • How it works: 

    Semaglutide works by mimicking a hormone called glucagon-like peptide-1 (GLP-1) that targets areas of the brain that regulate appetite and food intake. The medication dose may be increased gradually over 12 weeks to 2.4 mg once weekly to reduce gastrointestinal side effects.


    Some reported benefits of Semaglutide include:

    • Reduced body weight, lipid, blood pressure, inflammatory markers & oxidative stress
    • Suppresses Appetite
    • Enhances insulin synthesis & secretion
    • Promotes satiety (sensations of fullness in the brain)
    • And more

     Dosing medication is done in phases: 

    • Phase I (Month 1)- consists of 0.25mg/0.5mg/ml  of Semaglutide/Cyanocobalamin  given subcutaneously Once every week for 4 weeks.
    • Phase II (Month 2)- consists of 0.5mg/0.5mg/ml  of Semaglutide/Cyanocobalamin  given subcutaneously Once every week for 4 
      weeks.
    • Phase III  (Month 3)- consists of 1mg/0.5mg/ml of Semaglutide/Cyanocobalamin  given subcutaneously Once every week for 4 weeks.
    • Phase IV (Month 4) - consists of 1.7mg/0.5mg/ml of Semaglutide/Cyanocobalamin  given subcutaneously Once every week for 4 weeks
    • Any continuation past four months must be evaluated by a healthcare provider to ensure safety and efficacy for weight loss management.

     

    Side effects:

    Semaglutide: Common side effects may include nausea, vomiting, diarrhea, constipation, stomach pain, headache, tiredness, upset stomach, dizziness, bloating, belching, gas , stomach flu and heartburn. Serious side effects may include pancreatitis, gallstones, low blood sugar (hypoglycemia), kidney problems including kidney failure, chances in vision in peoples with type 2 diabetes, increased resting heart rate, depression or thoughts of suicide. 

     Cyanocobalamin: Common side effects may include dizziness, headache, feeling tired or weak, feeling nervous and excitable, upset stomach, diarrhea, or signs of a common cold.

    PLEASE call your healthcare provider if you experience any serious or unusual side effect or have any questions. 


    Informed Consent:

    By accepting the terms of this informed consent below you are in agreement with enrollment  in a medical weight loss program using semaglutide that involves a reduced calorie diet, increased physical activity & nutrition counseling.

    Do not use this medication if you or your family have ever had a type of thyroid cancer called Medullary Thyroid Carcinoma(MTC), or if you have an endocrine system condition called Multiple Endocrine Neoplasia syndrome type 2 (MEM2). 
    Tell your healthcare provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. It is not known if Semaglutide will cause thyroid tumors or MTC in people. In studies with rodents, Semaglutide and medications that work like Semaglutide causes thyroid tumors, including thyroid cancer.

    Female patient(s) are also agreeing that they understand the following:

    • pregnancy testing prior to initiating treatment
    • Immediate discontinuation if they suspect they could be pregnant any time after starting treatment
    • the need for contraception for two months after discontinuing semaglutide.


    FDA Approved Treatment for Weight Management



  • ** If a staff member has a needle stick injury with the potential for blood-to-blood transmission with the participant, the participant agrees to obtain formal blood testing to rule out the potential of communicable disease transmission via OSHA standards (HIV Hepatitis, etc).  JDL Ventures LLC, dba Ivy Smoothie Hydration & Wellness assumes all costs of further necessary testing.  Testing shall be performed within 24 hours of needle stick injury at a nearby lab location. 

    ** JDL Ventures LLC, dba Ivy Smoothie Hydration & Wellness reserves the right to refuse to initiate or continue IV treatment at any time based on RN or staff discretion. 

  • B-12 Vitamin injections

    We do have additional support programs that can help optimize your health & wellness. Please book a consultation to learn more.
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