Disclaimer

At Refresh Med Spa, we are NOT prescribing the Brand name Semaglutide BUT we are prescribing the generic compounded (Semaglutide) injection which is an injectable prescription medicine used for adults with obesity (BMI ≥30) or overweight (excess weight) (BMI ≥27) who also have weight-related medical problems to help them lose weight and keep the weight off.

• Semaglutide should be used with a reduced calorie meal plan and increased physical activity.
• Semaglutide contains semaglutide and should not be used with other semaglutide-containing products or other GLP-1 receptor agonist medicines.
• It is not known if Semaglutide is safe and effective when taken with other prescription, over-the-counter, or herbal weight loss products.
• It is not known if Semaglutide can be used safely in people with a history of pancreatitis.
• It is not known if Semaglutide is safe and effective for use in children under 18 years of age.

Do not use Semaglutide if:

• you or any of 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 (MEN 2).
• you have had a serious allergic reaction to Semaglutide or any of the ingredients in Semaglutide.

Before using Semaglutide, tell your healthcare provider if you have any other medical conditions, including if you:

• have or have had problems with your pancreas or kidneys.
• have history of diabetic retinopathy.
• have or have had depression, suicidal thoughts, or mental health issues.
• are pregnant or plan to become pregnant. Semaglutide may harm your unborn baby. You should stop using Semaglutide 2 months before you plan to become pregnant.
• are breastfeeding or plan to breastfeed. It is not known if Semaglutide passes into your breast milk.

 

Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Semaglutide may affect the way some medicines work and some medicines may affect the way Semaglutide works. Tell your healthcare provider if you are taking other medicines to treat diabetes, including Sulfonylureas or insulin. Semaglutide slows stomach emptying and can affect medicines that need to pass through the stomach quickly.

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.

Other possible, more serious side effects may include:  inflammation of your pancreas (pancreatitis), gallbladder problems, 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, kidney problems (kidney failure), serious allergic reactions, change in vision in patients with type 2 diabetes, increased heart rate, depression or thoughts of suicide, or possible thyroid tumors, including cancer.

 

Consent to treatment by provider:

I HAVE READ AND FULLY UNDERSTAND THIS CONSENT FORM AND I REALIZE I SHOULD NOT SIGN THIS FORM IF ALL ITEMS HAVE NOT BEEN EXPLAINED TO ME.

WITH MY SIGNATURE, I ACKNOWLEDGE THAT MY QUESTIONS HAVE BEEN ANSWERED FULLY, AND THAT I HAVE BEEN REQUESTED TO READ THIS FORM AND HAVE BEEN GIVEN AMPLE TIME TO UNDERSTAND ALL ITS CONTENTS.

By signing below, I give my consent for Refresh Med Spa to perform bloodwork, be evaluated and treated by a nurse practitioner and receive Semaglutide injections.