Medical Weight-Loss Program Intake Form

If you are under the care of another healthcare provider, it is important that you inform your provider of your use of Semaglutide.

Note: If you have any physical or emotional reaction to Semaglutide treatment, discontinue use immediately, and contact your provider to ascertain if the reaction is adverse or an indication of the natural course of your body's adjustment to the treatment.

Laboratory testing will be completed before treatment. Laboratory testing will not be used to diagnose or treat any illnesses

We may perform these potential blood tests:

• Full blood count;
• Liver function test;
• Kidney Function Tests; and
• Cholesterol levels, HbA1c, Glucose.

Several weeks to months of treatment may be required depending on your individual response to Semaglutide.

If a missed dose is more than 5 days late, the missed dose should not be taken, and the next dose should be taken at the normal time.

It is essential to combine eating, exercise, and behavioral modifications with Semaglutide.

Semaglutide is not used in combination with another GLP-1 receptor agonist, insulin, or insulin secretagogues (such as sulfonylureas) due to the risk of hypoglycemia.

Semaglutide causes a delay of gastric emptying and may impact the absorption of oral medications.

There are several special warnings and precautions for use of Semaglutide including warnings regarding pancreatitis, cholelithiasis and cholecystitis, thyroid disease, heart rate, dehydration, and hypoglycemia in people with type 2 diabetes.

Thyroid adverse events, such as goiter have been reported in patients with pre-existing thyroid disease. Semaglutide is used with caution in patients with thyroid disease.

A higher rate of cholelithiasis and cholecystitis (gallstone and gallbladder disease) has been observed in patients treated with Semaglutide. Cholelithiasis and cholecystitis may lead to hospitalization and cholecystectomy.

Signs and symptoms of dehydration, including renal impairment and acute renal failure, have been reported in patients treated with Semaglutide. There is the potential risk of dehydration in relation to gastrointestinal side effects and you should take precautions to avoid fluid depletion. Patients may also experience symptoms of increased heart rate.

Acute pancreatitis has been observed with the use of Semaglutide. Talk to your healthcare provider about the signs and symptoms of acute pancreatitis. Seek immediate medical attention if symptoms develop. If pancreatitis is suspected, Semaglutide should be discontinued; if acute pancreatitis is confirmed, do not re-start Semaglutide..

Semaglutide may cause dose-dependent and treatment-duration-dependent thyroid C-cell tumors. It is unknown whether Semaglutide causes thyroid C-cell tumors, including medullary thyroid carcinoma (cancer, MTC). Symptoms of thyroid tumors include a mass in the neck, difficulty swallowing, difficulty breathing or shortness of breath, persistent hoarseness.

Risks of Semaglutide treatment include but are not limited to:

• Common or very common: altered sense of taste, dry mouth, insomnia, burping; constipation; diarrhea; dizziness; dry mouth; gallbladder disorders; gastrointestinal discomfort; gastrointestinal disorders; insomnia; nausea; vomiting, hypoglycemia, dyspepsia, gastritis, gastro-esophageal reflux disease, flatulence, upper abdomen pain, abdomen distension, cholelithiasis, injection site reactions, fatigue, increased lipase and increased amylase.
• Uncommon: Malaise; pancreatitis; tachycardia; urticaria
• Rare: Renal impairment, allergic reaction, anaphylaxis

Do not take Semaglutide if any of the below contraindications apply to you:

• Aged under 18 or above 75;
• Severe renal/kidney impairment (with eGFR of 15 or below) or a history of renal disease;
• Severe hepatic/liver impairment;
• Personal or family history of medullary thyroid cancer (MTC);
• Hypersensitivity to Semaglutide or to any of the excipients: disodium phosphate dihydrate, propylene glycol, phenol and water for injection.
• Concurrent treatment with any other products for weight management;
• Weight problems related to endocrinological or eating disorders;
• Concurrent use of insulin or sulfonylurea;
• Concurrent use of warfarin (more frequent INR monitoring required);
• Concurrent use of any medicinal products with may cause weight gain;
• Pregnancy, breastfeeding or trying to/planning to become pregnant;
• Congestive heart failure;
• History of pancreatitis, gallbladder disease, inflammatory bowel disease, diabetic gastroparesis and/or
• Patients with a personal or family history of MEN 2 (Multiple Endocrine Neoplasia syndrome.

The below drugs interact with Semaglutide and treatment of Semaglutide should not be used concurrently:

Alogliptin, Biphasic insulin aspart, Biphasic insulin lispro, Biphasic isophane insulin, Canagliflozin, Dapagliflozin, Dulaglutide, Empagliflozin, Exenatide, Glibenclamide, Gliclazide, Glimepiride, Glipizide, any insulin including aspart, degludec, detemir, glargine, glulisine, lispro, isophane, zinc suspension, Nateglinide, Pioglitazone, Repaglinide Saxagliptin, Sitagliptin, Vildagliptin, Tolbutamide.

This office is required to notify you in writing, that by law, we must maintain the privacy and confidentiality of your Personal Health Information. In addition, we must provide you with written notice concerning your rights to gain access to your health information, and the potential circumstances under which, by law, or as dictated by our office policy, we are permitted to disclose information about you to a third party without your authorization. Below is a brief summary of these circumstances.

1. Treatment purposes - discussion with other health care providers involved in your care.
2. Inadvertent disclosures - open treating area mean open discussion. If you need to speak privately to the doctor, please let our staff know so we can place you in a private consultation room.
3. For payment purposes - to obtain payment from your insurance company or any other collateral source.
4. For workers compensation purposes - to process a claim or aid in investigation.
5. Emergency - in the event of a medical emergency we may notify a family member.
6. For Public Health and Safety - to prevent or lessen a serious or eminent threat to the health or safety of a person or general public.
7. To Government Agencies or Law Enforcement - to identify or locate a suspect, fugitive, material witness or missing person.
8. For military, national security, prisoner, and government benefits purposes.
9. Deceased persons - discussion with coroners and medical examiners in the event of a patient’s death.
10. Telephone calls or emails and appointment reminders - we may call your home and leave messages regarding a missed appointment or apprize you of changes in practice hours or upcoming events.
11. Change of ownership- in the event this practice is sold, the new owners would have access to your PHI. 

YOUR RIGHTS:

1. To receive an accounting of disclosures.
2. To receive a paper copy of the comprehensive “Detail” Privacy Notice.
3. To request mailings to an address different than residence.
4. To request Restrictions on certain uses and disclosures and with whom we release information to, although we are not required to comply. If, however, we agree, the restriction will be in place until written notice of your intent to remove the restriction.
5. To inspect your records and receive one copy of your records at no charge, with notice in advance.
6. To request amendments to information. However, like restrictions, we are not required to agree to them.
7. To obtain one copy of your records at no charge, when timely notice is provided (72 hours). X-rays are original records, and you are therefore not entitled to them. If you would like us to outsource them to an imaging center, to have copies made, we will be happy to accommodate you. However, you will be responsible for this cost.

NOTICE REGARDING YOUR RIGHT TO PRIVACY continued…

I have received a copy of the Patient Privacy Notice. I understand my rights as well as the practice’s duty to protect my health information and have conveyed my understanding of these rights and duties to the doctor. I further understand that this office reserves the right to amend this “Notice of Privacy Practice” at a time in the future and will make the new provisions effective for all information that it maintains past and present. I am aware that a more comprehensive version of this “Notice” is available to me. At this time, I do not have any questions regarding my rights or any of the information I have received.