Forest Lounge | Initial Semaglutide Telehealth Consultation Agreement

The Forest Lounge Medical Center offers convenient and affordable healthcare services through telemedicine. This mode of healthcare delivery is particularly suitable for non-emergency situations.

All Staff and Medical Providers at The Forest Lounge are guided by the American Medical Association’s Code of Medical Ethics and we adhere deeply to the ethos that “medicine is practiced one patient at a time and each patient has individual needs and vulnerabilities.”

THE INITIAL SEMAGLUTIDE TELEHEALTH CONSULTATON INCLUDES:

The Cost of the Initial Telemedicine Consultation includes Bloodwork*, Review of your Medical History and a Discussion about your Health and Wellness Goals with a Qualified Forest Lounge Medical Professional.

*If you have had Bloodwork done within the last year, immediate Bloodwork is not required unless a Forest Lounge Medical Professional determines otherwise. We will carefully assess any recent bloodwork you have undergone to determine if additional tests are necessary for Semaglutide Treatment. Patients will not incur any additional fees for these assessments. These tests are commonly comprised of an obesity lab panel, evaluating CBC (complete blood count), CMP (comprehensive metabolic panel), lipids (cholesterol levels), A1C (glycated hemoglobin for diabetes), TSH (thyroid-stimulating hormone), and insulin levels.

SEMAGLUTIDE PROGRAM DETAILS:

NO INSURANCE SURPRISES. NO CO-PAY. NO HIDDEN FEES:

After the Initial Telemedicine Consultation and Upon Approval by a Qualified Forest Lounge Medical Professional, Patients can expect:

One Cost. Billed Monthly. No Contracts. Pay as you go. No need to worry about Cancelling a Subscription or getting that surprise Medical Bill. Straightforward is what our Patients prefer.

SEMAGLUTIDE PROGRAM COST:

$399 Per month. No Hidden Fees. One Flat Cost.

Includes 4 once a week injections:

+ Week 1-4 at .25mg per wk
+ Week 5-8 at .50mg per wk
+ Week 9-12 at .75mg per wk

Given the individualized nature of patient care, following Week 9-12, Injections will continue every 4 weeks as usual, but may vary per individual. Common dosages ramp up as follows:

+ 4 injections at 1mg per wk
+ 4 injections at 2mg per wk
+ 4 injections at 2.4mg* per wk

Please Note: 2.4mg* of Semaglutide is considered the weekly Maximum Dose.

SEMAGLUTIDE PROGRAM INCLUDES:

+ Personalized Weight Mgmt Plan
+ Weekly Semaglutide Medication
+ FreeStyle Libre 3 Glucose Monitoring System
+ 1 Month Telehealth Followup Visits
+ Medically Surpervised Monitoring
+ Lab Panel* / Routine Bloodwork / Lab Analysis
+ All Supplies Needed (Syringes, etc.)
+ Free Medication Delivery to your Door

* Please Note our Full Comprehensive Lab Panel: Includes full blood profile (with iron and ferritin), organ function evaluation, hormone panels (estrogen, testosterone, FSH, LH), thyroid function, A1C, cholesterol, inflammation markers, stress markers, and a selection of vitamins (b12 & D). This is much more than most would have done at an annual physical.

PATIENT INFORMATION:

First and Last Name*

First NameLast Name

Date of Birth*

Date

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Please Provide your Height and Weight*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

YOUR FIRST TELEMEDICINE CONSULTATION:

WE WILL CONTACT YOU WITHIN ONE BUSINESS DAY TO SCHEDULE YOUR INITIAL CONSULTATION USING THE PHONE NUMBER YOU PROVIDE. IF YOU HAVE A SPECIFIC DAY THAT WORKS BEST FOR YOU, WE WILL ALSO MAKE EFFORTS TO CALL YOU DURING YOUR PREFERRED DAY INDICATED BELOW.

Best Phone Number to Reach You*

Please enter a valid phone number.

Preferred Days & Times Reach You

TERMS OF SERVICE AGREEMENT:

Requests for telehealth must be confirmed and scheduled by our office prior to the telehealth visit. Prior to the Initial Semaglutide Consultation, I agree to fill out The Medical Intake Form which will be emailed upon completion of this Agreement.

I, {firstAnd}, acknowledge I am paying for a telemedicine consultation with a Qualified Forest Lounge Medical Professional and the outcome will be based solely on the Medical Professional's discretion. The Initial Semaglutide Consultation fee is non-refundable.

Patients First and Last Name (Print)*

Today's Date*

Date

Patient Email*

example@example.com

Please sign below. I acknowledge and agree that I have read the Initial Semaglutide Consultation Agreement. I authorize The Forest Lounge to contact me to schedule a telemedicine visit once payment is received below.*

CHECK OUT:

Forest Lounge Services*

Initial Semaglutide Telemedicine Consultation - No BloodworkYou have had Bloodwork Done within the Year and will provide copies at your First Consultation. The Cost of the Initial Telemedicine Consultation includes Bloodwork Review, Review of your Medical History and a Discussion about your Health and Wellness Goals with a Qualified Forest Lounge Medical Professional.

$299.00 Quantity

Initial Semaglutide Telemedicine Consultation - Bloodwork NeededA Forest Lounge Medical Professional will help you arrange a Bloodwork Appointment. The Cost of the Initial Telemedicine Consultation includes Bloodwork, Bloodwork Analysis, Review of your Medical History and a Discussion about your Health and Wellness Goals with a Qualified Forest Lounge Medical Professional.

$399.00 Quantity

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Total

$0.00

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After processing, a receipt will be sent to your email. Please feel free to call us with any questions.

THE FOREST LOUNGE MEDICAL CENTER
173 E. Laurel Ave. • Lake Forest • IL • 60045 • Phone: 224.899.2000 • Fax: 224.899.1999 Email: info@myforestlounge.com • Website:www.myforestlounge.com