MEDICAL WEIGHT LOSS INTAKE FORM

I, name, do hereby authorize Dr. Boudreaux to assist me in weight reduction. I fully understand that this program shall consist of a reduction in caloric intake, regular exercise and behavioral lifestyle changes.

Regarding the use of the compounded injectable weight loss medication, Semaglutide. I understand that these medications are very new to the market and some issues may not have yet been discovered. There are potential risks involved.

Black Box Warning: Thyroid C-cell Tumor risk, Patient/Family history of medullary thyroid cancer, (MEN 2) multiple endocrine neoplasia syndrome. These are contraindications for using this medicine.

I do not have any history of the above.

Severe reactions include: Thyroid Cancer, Gallbladder Disease, Pancreatic Disease, Acute Kidney Injury, Chronic Kidney Disease Exacerbation and Hypersensitivity Reaction to the Medication.

Common Side Effects: Heart Rate Increase, Vomiting, Nausea, GERD, Heartburn, Abdominal Pain, Bloating, Dizziness, Headache, GallStones, Low Blood Sugar, Kidney disease, Retinal Disorders, Nervousness, Constipation, Headaches, Dry Mouth and Injection Site Infection.

I understand that these and other risks could, on occasion, be serious and possibly permanently disabling.

I understand that if I develop side effects from the medication, I will discontinue taking the medication and notify Dr Boudreaux, as well as my primary care physician, immediately and in the event the problem is severe, I will go to the nearest Emergency room for immediate care.

I do not have a history of alcohol abuse, drug abuse, schizophrenia, manic-depressive illness, or eating disorder, since these conditions constitute a contraindication to the use of appetite suppressants.

I agree not to take any other weight loss medications, other than those prescribed by Dr. Boudreaux and further agree to inform the staff of ANY changes in my medication or medical history.

I understand the risk associated with being overweight/obese, which include the possibility of death, high blood pressure, diabetes, heart attack and heart disease, stroke, arthritis of the joints, hips, knees and feet, and gallbladder disease. I also understand that rapid weight loss programs may increase the incidence of symptomatic gallbladder disease.

There is no guarantee that this program will work for me. I understand that I must follow the program as directed, in order to achieve weight loss. By consenting to treatment, I agree to pay, in full, all visits and charges incurred at each visit. I understand that these charges are not covered by insurance and Dr. Boudreaux does not provide or fill out claim forms for insurance purposes. I also understand that no refunds are given out.

I have read the information regarding risks and benefits weight loss therapy and I understand the possible complications of injection therapy. I understand the benefits and risks of this injection. I hereby release Dr Boudreaux and associated staff, and any other organizations associated with this injection, their affiliated, associated and related entities, along with the directors, officers, employees, successors and all such persons from any and all liability arising from or in any connection with this injection. I am in good health and/or I have my physician’s approval. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.

I certify that I have read, and fully understand, the above paragraphs, and that I have had sufficient opportunity for discussion and to ask questions, and all of my questions have been answered to my satisfaction. I have adequate knowledge upon which to give consent to the proposed treatment. I consent to having injections today and for all subsequent treatments.

Name

First NameLast Name

Date

Signature

MEDICAL WEIGHT LOSS - PATIENT INTAKE

MEDICAL HISTORY FORM

REVIEW OF SYSTEMS FORM

EYES AND VISION

EAR, NOSE, THROAT

HEART & CARDIOVASCULAR

RESPIRATORY

ENDOCRINE

MUSCULOSKELETAL

GASTROINTESTINAL

GENITOURINARY

SKIN

NEUROLOGICAL

HEMATOLOGIC/LYMPHATIC

LIFESTYLE HISTORY FORM