Semaglutide Shipped to your Doorstep

Name

First NameLast Name

Email

example@example.com

Birthday (MM/DD/YY)

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

What is your current height and weight?

What is your goal weight?

What is the reason you are hoping to lose weight?

Have you attempted to loose weight before? If so, how?

Do you currently have any medical conditions or concerns?

Do you have a history of any of the following: pancreatitis, extremely low blood sugar, thyroid tumors?

Do you have any allergies?

What medications are you currently taking?

Are you currently on blood thinners?

What is your weekly alcohol intake? Do you smoke?

How would you describe your current energy levels?

I understand this program REQUIRES A PREREQUISITE: Patients receiving medical treatments are required by the state of Texas to have an initial teleheath session with our Physician Assistant. This call takes no more than five minutes and allows you to safety receive your medication. Cost of session is included with the bundle. Please state "yes" below.

I understand in order to be eligible for this program, my BMI must be 25 or higher. As the patient, I have checked my BMI, and it is at 25 or higher. Please state "yes" below if so. Link to BMI calculator: https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html

INFORMED CONSENT

SEMAGLUTIDE WEIGHT LOSS PROGRAM

Injectco has explained the program to me in full detail and I understand the program involves a weekly self-administered injection.

I understand that monthly visits to the clinic are required to track progress and give support from provider.

I have fully disclosed any medical conditions in my Intake Forms.

I have also fully disclosed all medication that I am currently taking.

I am aware that Injectco does not use this weight loss program with people who have any of the following conditions and I confirm that none of these apply to me:

Uncontrolled Diabetes

Seizure Disorders

Uncontrolled High Blood Pressure

Blood Clots

Pituitary or Ovarian Tumours

Stroke History

Hyperthyroidism

Unstable Angina

I confirm that I am not pregnant nor currently breastfeeding.

The main benefits of these injections may include:

Semaglutide is 94% similar to natural human GLP-1 and therefore acts as a physiological regulator of appetite and thereby reducing food intake by reducing feelings of hunger and increasing feelings of fullness/satiety.

It is a newly licensed medication indicated for the treatment of type-2 diabetes. It is currently undergoing clinical trial to gain a license for the treatment of obesity. In the meantime, your medical practitioner may prescribe this medication for you 'off-label'

For long term success, the treatment needs to be combined with lifestyle changes including nutritional, exercise and behavioural habits.

Weight loss can lead to secondary benefits by improving weight loss related health problems such as cardiovascular risk factors (including hypertension, blood glucose levels and waist circumference) and physical health-related quality of life.

I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent.

I am aware that although the use of Semaglutide is generally free of negative side effects, there is the possibility of the following: headache, fatigue, nausea/vomiting, constipation, bruising at injection site, heartburn, abdominal pain, and temporary variation in menstrual cycle. Other possibilities include: prostate enlargement, breast tenderness and ovarian hyperstimulation syndrome.

The program has been explained to me and I have been given the program handout. As well, I have been instructed on how to self-administer the weekly injection. I give my informed consent for this Weight Loss Program. I release any and all liability from Injectco regarding this Semaglutide weight loss program.

Since every human being is unique, we cannot guarantee any specific result from this treatment. Medication and/or medical conditions may have a negative impact on the outcomes as well as lifestyle factors.

It is essential to engage in a monthly face-to-face reviews with your provider throughout the treatment program.

Patients need to follow the instructions carefully as provided separately in the patient instruction handout. Patients must agree to notify their practitioner of any contraindications or side effects of the treatment.

I understand if I, as the patient, refuse payment after services are rendered, Botox Bar reserves the right to charge the card on file for the full amount of services applied.

I understand that under NO CIRCUMSTANCES will any refunds be given. I understand if any of the medications or supplies are damaged in shipment, Botox Bar is not liable.

I understand when my medication runs low, it it the responsiblity of myself, as the patient, to call botox bar at 817-533-7676 when I am needing to be shipped a new vial.

I agree the information in the form is true and complete, and hereby release all liability.

Signature*

My Products

One Vial (1)

What is included? Initial PA telehealth exam + visit, 4-6 months of medication (depending on current dosage), shipping charges, all supplies necessary, and video chats with an RN as needed.

$1,500.00 Quantity
Item subtotal:$0.00

Two Vials (2)

What is included? Initial PA telehealth exam + visit, 6-8 months of medication (depending on current dosage), shipping charges, all supplies necessary, and video chats with an RN as needed.

$2,750.00 Quantity

Three Vials (3)

What is included? Initial PA telehealth exam + visit, 8+ months of medication (depending on current dosage), shipping charges, all supplies necessary, and video chats with an RN as needed.

$4,000.00 Quantity

Total

$0.00

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BriteBody Clinical Weight Loss Program

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