IR | Patient Intake Form

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Simply fill out the short form below, and we'll connect you with one of our US-licensed medical providers.
What are you looking to accomplish by becoming an Instant Rejuvenate patient?*

Lose weightImprove general physical healthIncrease confidence about my appearanceIncrease energy for enjoyable activitiesI have another goal not listed above

Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number*
Email*
example@example.com

This will be the address the pharmacy will ship medication to.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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By signing below, I understand and agree to the following:
Semaglutide Treatment Consent*

I, the undersigned, hereby provide my informed consent for the treatment with semaglutide, tirzepatide or triple agonist peptide (TAP) to aid weight loss. Before proceeding with the treatment, I have been informed of the potential risks, benefits, and alternatives associated with this treatment. I have had the opportunity to discuss my concerns and questions with my healthcare provider, and I am aware of the following information:
1. Potential Benefits:

- Effective weight loss support

- Imporved control over appetite ad hunger

- Enhanced metabolism and fat burning

- Increased motivation for long-term weight management

- Potential improvement in related health conditions (e.g., diabetes, high blood pressure)

2. Potential Risks and Side Effects:

Like any medical treatment, the use of semaglutide carries certain risks and side effects, including but not limited to:

- Nausea and vomiting

- Diarrhea or constipation

- Headache

- Dizziness

- Abdominal discomfort

- Injection site reactions

3. Alternatives to Treatment:

There are alternative weight loss methods including dietary changes, increased physical activity, behavioral therapy and other weight loss medications. These options were discussed with me, and I chose to undergo the semaglutid weight loss treatment. I understand that the decision to undergo this treatment is voluntary, and I chose to proceed with this treatment.

My healthcare provider has discussed the risks, benefits and alternatives of semaglutide and tirzepatide with me. He/she has answered my questions and has ensured that I understand the treatment's implications.
Semaglutide Treatment Policy*

I understand that results in medical weight loss may vary from patient to patient, and various factors influence individual outcomes. I consent to be seen by the doctor virtually via telehealth services. I understand Instant Rejuvenate provides business services to the doctor. I agree to proceed with my consultation and treatment as set by the doctor. I hereby provide my informed consent to undergo semaglutide weight loss treatment at the Instant Rejuvenate clinic. I acknowledge the success of this weight loss program relies on my strict adherence to the instructions provided by the medical team, including following a low-carb diet and incorporating regular physical activity into my routine. I understand and acknowledge that semaglutide requires a sufficient amount of time to produce the desired effects, a minimum commitment of six months to the treatment plan is necessary.
Refund Policy*

I understand and accept that all fees paid for our medical weight loss treatment services are non-refundable. Regardless of the outcomes achieved or circumstances arising during the course of treatment, no refunds will be provided. I understand that I am responsible for the full payment of the agreed-upon fees for the medical weight loss treatment services, irrespective of any subsequent decisions to discontinue or alter the treatment.
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