Weight Loss Over 40
Complete this form and our office will be in touch via call/text shortly! Please note, this program is for AZ residents only.
Name
First Name
Last Name
Height
Weight
BMI: You can calculate your BMI by visiting this site: https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm
Email - I agree to receive occasional emails from my provider about sales and other important information regarding my healthcare (no spam, we promise!)
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you currently pregnant or actively trying to get pregnant?
Yes
No
Do you have a personal history of Pancreatitis?
Yes
No
Do you have a personal OR family history of Medullary Thyroid Cancer?
Yes
Type option 2
Type option 3
Type option 4
Do you have a personal or family history of Multiple Endocrine Neoplasia Syndrome Type II (MEN-2)?
Yes
No
List ALL prescribed medications and OTC supplements you are currently using
Have you been on Semaglutide (Wegovy, Ozempic, Rybelsus) before?
Yes
No
If so, what dose were you previously on?
Have you been on Tirzepatide (Mounjaro) before?
Yes
No
If so, what dose were you previously on?
I understand this medication may have the following side effects.
Nausea
Vomiting
Constipation or Diarrhea
Decreased Appetite
Dizziness
Fatigue
Hypoglycemia (Low Blood Sugar)
Pancreatitis
Gallbladder disorders
Depression including suicidal ideation
Allergic Reaction
Because every person is different, we cannot make any guarantees that this medication will produce the desired effects.
I understand and agree
I understand I may experience any of the above listed side effects including others that are not listed.
Yes
No
I understand I should be under the care of a Primary Care Provider for all health issues and understand Feel Better AZ and Dr. Ambrosia Boyd, DNP is NOT my primary care provider
I understand and agree
Semaglutide and Tirzepatide are medications that may help you lose weight by reducing feelings of hunger and increasing feelings of fullness/satiety. These medications may by produced by compounding pharmacy and may have additional products such as Vitamin B-12 added to them. The compounded formulation is not FDA approved. This medication may be used off-label of it’s FDA approved usage. For long term success, you’ll need to combine this medication with lifestyle changes including nutritional, exercise, and behavioral habits. Weight loss can lead to secondary benefits by reducing your risk of heart disease and diabetes.Alternative therapies to this medication include: -Dietary/Lifestyle modifications -Oral medications -Weight loss programs such as Optavia, Weight Watchers, etc.Contraindications: You should NOT use this medication if you have a personal or family history of: -Medullary Thyroid Cancer -Multiple Endocrine NeoplasiaI acknowledge I may refuse treatment with any of the aforementioned medications.I agree to immediately report to my practitioner’s office any adverse reaction or problems that might be related to my therapy.I understand that Ambrosia Boyd, DNP will monitor my treatment in an effort to prevent any side effects but cannot guarantee that I will not experience any side effects or adverse reactions.I understand that, as with any health treatment, there is no guarantee I will obtain satisfactory results through the use of this therapy.NOTE: DO NOT SIGN THIS FORM UNLESS YOU HAVE READ IT AND FEEL THAT YOU UNDERSTAND IT. DO NOT SIGN THIS FORM IF YOU HAVE TAKEN MEDICATIONS WHICH MAY IMPAIR YOUR MENTAL ABILITIES OR IF YOU FEEL RUSHED OR UNDER PRESSURE. BY SIGNING THIS FORM, YOU ARE ALSO ACKNOWLEDGING THAT ALL YOUR QUESTIONS WERE ANSWERED TO YOUR SATISFACTION PRIOR TO SIGNING THIS FORM. I certify that I have read the foregoing Informed Consent, discussed the issues noted above, and have had ample opportunity to ask questions, and agree and accept all the terms above. By signing this form, I understand the possible risks associated with this treatment. I understand that Ambrosia Boyd, DNP will monitor my treatment in an effort to prevent any side effects but cannot guarantee that I will not experience any side effects or adverse reactions. I understand that, as with any health treatment, there is no guarantee I will obtain satisfactory results through the use of this therapy. I understand the use of this treatment does not preclude me from using other treatments as well, though I recognize that I should inform any practitioners I am seeing about the various treatments I am using. I have read and agree to the above informed consent. Required
I have read this form and have had a chance to ask any questions. I have been informed I may experience any of the side effects listed above. It is my desire to proceed with treatment with the above mentioned
Submit
Submit
Should be Empty: