Prior to starting Rejuvené’s Semaglutide Weight Loss program, it is important to disclose the following:

•  Semaglutide for weight loss is currently, as of June 2014, FDA approved only under the brand name, Wegovy. 
• Our weight loss program does not use the brand name Wegovy and therefore is not using a FDA approved medication for weight loss. We use Semaglutide that is compounded with other components such as Vitamin B12 or other compound.
• It is important to note that the studies conducted on Semaglutide for weight loss were not done with a compounded version and the effectiveness of Semaglutide in a compounded version has not been established.
• Semaglutide is more commonly associated with nausea, heartburn, vomiting and constipation. Less common side effects include abdominal pain, gastroparesis, pancreatitis, gallbladder stones or inflammation, acute kidney injury, low blood glucose, electrolyte imbalance, diabetic retinopathy, headache, fatigue and suicidal ideation.
• Semaglutide should not be used in patients with a history of or family history of medullary thyroid cancer or multiple endocrine neoplasia.
• Semaglutide should not be used if the patient has a history of insulin-dependent diabetes, diabetes utilizing sulfonylureas, patients with history of low blood sugar (hypoglycemia) or patients with acute or recent Pancreatitis or active gall bladder disease.
• Although Semaglutide under the supervision of a physician is generally considered safe for use in the appropriated screened patient, the long-term effects of this medication on diseases such as pancreatic, thyroid or other cancers or diseases is not well known.

By signing this disclosure form, I have read and understand the aforementioned and agree to assume the risks contained within.

Incomplete Forms

• All intake forms are to be completed for review prior to the consultation with the physician and start of injections. Clients will not be allowed to be evaluated by the physician and start the injections until all required forms are completed in their entirety and returned.  
• Forms are to be completed and returned at least 48 hours prior to meeting with the physician to allow adequate time for review.

No Shows

• We require a 24-hour notice for cancellation of an appointment.  If a client cancels less than 24-hours before his/her appointment, it will be considered a no show. 
• No shows to any scheduled appointment will not be tolerated. If a client has 2 no shows during the program, he/she will be dismissed from the program.
• If a client is dismissed from the program for no shows, no refunds will be given.

Late Shows

• It is expected that each client be on time for each scheduled appointment.  There will be other clients scheduled at regular intervals.  If a client is late for their scheduled appointment, their availability time with the provider will not be extended.  If the provider cannot provide the appropriate services in the time remaining for the appointment, the appointment will have to be rescheduled.
• Recurring late shows will not be tolerated. If a client has 4 late shows, he/she will be dismissed from the program.
• If a client is dismissed from the program for late shows, no refunds will be given.

Refunds

• Clients shall be due a refund of their consultation and lab fee minus $100 if they do not go forward following the consultation but before labs are completed.
• Clients shall be due a refund of their consultation fee minus $100 if they do not go forward following consultation.
• If a client ends the program before the end of the dosing cycle, refunds will not administered for that dosing cycle.  If a client has prepaid for more than one dosing cycle, he/she shall be entitled to a refund of the additional prepaid months.
• There will be no refunds if a client is dismissed from the program because of “no shows” or “late shows”.

I have read, understand and agree to be compliant with the above policies,

By my signature below, I hereby willingly request and consent to Semaglutide, L-Carnitine or B-12 injections by Rejuvené MedSpa and Wellness Center dba Executive Medicine or its affiliate. While shown to be effective in weight loss, I understand that there is no warrant or guarantee of results from using Semaglutide weekly injections.

1. I understand that as part of this program I will be required to complete a Medical History and meet with a Physician with Rejuvené MedSpa and Wellness Center dba Executive Medicine to determine my candidacy. I understand that initial blood tests will be required to evaluate for conditions that could disqualify me from the program or require any prior treatment before starting the program.

2. I understand that I may develop side effects that may include, but not limited to: low blood sugar, electrolyte imbalance, worsening kidney function, nausea, vomiting, diarrhea, constipation, indigestion/gastric reflux, gastroparesis, gall bladder inflammation, pancreatitis, abdominal cramping, abdominal pain, headache or suicidal ideations. I agree to immediately report any problems that might occur to Rejuvené MedSpa and Wellness Center dba Executive Medicine, as well as my Primary Physician during the treatment program.

3. I understand that there could be risks involved, as there are with all medications. Failure to comply with the dosage recommendation and dietary restrictions could alter the weight loss results.  I attest that I have read, understand and agree to the Rejuvené MedSpa and Wellness Center disclosures concerning Semaglutide and program polices.

4. I agree that I am, and will be, under the care of my primary medical provider for all other medical conditions.

5. I understand that treatments for weight loss are rarely covered by insurance companies. We do not accept or bill insurance for this program.

6. I understand that medication is ordered on a per patient basis and that I am to pay in advance for the full month of injections. At any point I can choose to discontinue the program.  If I choose to end the program, I understand that I will not be eligible for a refund or proration for funds paid for the 4-week dosing cycle in which I am currently participating.

7. I acknowledge that all statements provided on the Medical History Forms are true and accurate to the best of my knowledge and that my treatments will be based on the information provided herein and if I willingly withhold information or do not inform Rejuvené MedSpa and Wellness Center dba Executive Medicine of any changes in my medical condition (including pregnancy), I accept full liability for any consequence that may arise therefrom.

8. I acknowledge that Semaglutide is in high demand throughout the country and despite Rejuvené MedSpa and Wellness Center dba Executive having multiple U.S. based suppliers, it’s possible that the medication may become unavailable at any time during the program.  

9. SEMAGLUTIDE CONTRAINDICATIONS: I UNDERSTAND THAT IF I HAVE ANY OF THE FOLLOWING, I SHOULD NOT TAKE SEMAGLUTIDE INJECTIONS: diabetic retinopathy (a type of damage to the eye from diabetes), Type I Diabetes, insulin-dependent diabetes, diabetes & taking sulfonylurea, history of low blood sugar, decreased kidney function, pancreatitis, gallbladder problems,  multiple endocrine neoplasia type 2, medullary thyroid cancer or family history of medullary thyroid carcinoma.

10. I have read and understand all the above statements and conditions and have been informed of potential side effects and risks that may be associated with the use of Semaglutide. I fully understand what I am signing and hereby request and consent to this weight-loss treatment.