Semaglutide Registration & Consent

Semaglutide Registration & Consent

Fill out the form below to register and consent for Semaglutide Weight Loss Therapy at Revolutionary MD!
Today's Date*

MonthDayYear
Date
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Weight | Height (Estimated)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Email*
example@example.com
Phone Number*
Employer*
Occupation*
Marital Status*

MarriedDivorcedSingle
Gender*

FemaleMaleNon-Binary
How did you hear about us?*
What goals are you seeking to achieve through Semaglutide Weight Loss Therapy?*
Have you tried Semaglutide Weight Loss Therapy in the past?*
Emergency Contact*

NamePhoneRelationship

Financial Policy Agreement
ALL PATIENTS NEW TO SEMAGLUTIDE WEIGHT LOSS THERAPY ARE REQUIRED TO COMPLETE AN IN-PERSON CONSULTATION WITH A REVOLUTIONARY MD NURSE PRIOR TO TREATMENT:
- Initial consultation MUST be done in person
- This initial consultation is $395 and includes 3 follow-up calls
- This initial consultation is a one-time occurrence and cost
- Each vial of Semaglutide is $450 and each pack of 20 syringes are $25
- If you require Semaglutide to be mailed to your address, you are financially responsible for any and all shipping costs
- We accept cash, checks, MasterCard, and Visa
- This therapy is not covered by insurance, but you may be able to use a health saving account to cover this.
- The fee for a returned check is $50.
- Patients are responsible payment after completing patient visit on day of service.
- Appointments cancelled less than 24 hours prior to a scheduled time may be subject to a $50 cancellation fee
- 3 or more missed appointments without notification will result in dismissal from the practice.
By signing below, you confirm that you have read and agree to the policies presented above.
Patient Signature*

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Today's Date*

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Date

Semaglutide Informed Consent
I am executing this consent to conﬁrm my decision to purchase peptides and to verify my understanding of the risks and alternatives to treatment with peptide therapy.

The goals and possible beneﬁts of this therapy are to try and prevent, reduce or control the

dysfunction associated with the aging process, through hormonal balancing, control of oxidative stress, and stimulating the body's own innate repair systems. However, I understand that this treatment may be viewed by the mainstream medical community as new, controversial, and unnecessary by the Food and Drug Administration (FDA).
Risks:

The following are examples of some of the possible minor risks/adverse reactions reported for the peptide therapy that may be prescribed for me. At prescribed doses, there are not expected to be any signiﬁcant risks/adverse reactions as long as full medical disclosure is achieved from the patient during the total time of therapy.

Some adverse reactions may include but are not limited to injection site redness, ﬂushing, transient high blood sugar, development of antibodies peptides, and water retention. These side eﬀects are dose related and usually eliminated by adjusting the dosage. This drug should not be used in patients with known cancer or are pregnant.

By signing this form, I understand the possible risks associated with this treatment.

I understand that Dr. Grover and his medical staff will monitor my treatment in an eﬀort to manage 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 certify that I have read the foregoing Informed Consent, discussed the issues noted above, had opportunities to ask questions, and agree and accept all of the terms above.
Patient Signature*

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Patient Full Name*

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Today's Date*

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Date
We welcome you to the Revolutionary MD Practice by Dr. Fred Grover!
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Semaglutide Registration & Consent

Health Information Questionnaire

Financial Policy Agreement

By signing below, you confirm that you have read and agree to the policies presented above.

Semaglutide Informed Consent