Lean Life MD Disclosures Form

Lean Life Medical Intake Form

Medical History
Name*

First NameLast Name
Date Of Birth*

MonthDayYear
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Sex*

MaleFemaleDecline to Answer
Height*
Weight*
Are you currently under the care of a physician?*

YesNo
Please list all medications you are currently taking:*
Do you take any vitamins, herbal, natural or homeopathic supplements?*

YesNo
List All Known Allergies:
Do you have or have you ever had any of the following conditions? (Check all that apply)**

CancerGallbladder ProblemsHyper/hypopigmentationKidney ProblemsHormone DeficiencyDiabetesSkin DisordersPancreatitisHepatitisGastroparesisHigh Blood PressureKeloid ScarringThyroid ProblemsBlood Clotting DisordersChronic Abdominal PainIllness In The Last 30 DaysNONE OF THE ABOVE
If you checked any of the above boxes, please give name of condition and list any medications taken to treat:

Do you have a history of any of the following?*

	Yes	No
Medullary Thyroid Cancer
Multiple Endocrine Neoplasia
Pancreatic Cancer
Type I Diabetes

Do you have any other health problems or medical conditions not listed above?*

YesNo
Have you had any aesthetic procedures in the last 90 days?*

YesNo
Are you pregnant or trying to get pregnant?*

YesNo
Have you ever had an allergic reaction to any of the following? (Check all that apply.)*

LatexHydroquinoneLidocaineFoodSteroidsAspirinNONE OF THE ABOVEOther

Does anyone IN YOUR FAMILY have a history of any of the following?*

	Yes	No
Medullary Thyroid Cancer
Multiple Endocrine Neoplasia
Pancreatic Cancer
Type I Diabetes

Do You Exercise Regularly?*

YesNo
Do you practice yoga or meditate regularly?*

YesNo
Do you drink soda?*

YesNo
Do you drink alcohol?*

YesNo
Do you smoke cigarettes or vape?*

YesNo
Do you use cannabis?*

YesNo
Please list all surgeries and dates:
Signature*

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Date

Lean Life MD Weight Management Program Policies
Name*

First NameLast Name
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 24 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, they 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 medication fees if they do not go forward following the consultation but before medication has been ordered.
- If a client ends the program before the end of the dosing cycle, refunds will not administered for that dosing cycle.
- 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,
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Lean Life MD Disclosures Form
Name*

First NameLast Name
Disclosures
Prior to starting Lean Life MD'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.
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Consent For Treatment

Semaglutide Assisted Weight Loss Program
Name*

First NameLast Name
Date Of Birth*

MonthDayYear
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
By my signature below, I hereby willingly request and consent to Semaglutide by Medmuse LLC dba Lean Life MD 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 Form and meet with a Physician/Nurse Practitioner with Medmuse LLC dba Lean Life MD to determine my candidacy. I understand that a telemedicine consultation 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 Medmuse LLC dba Lean Life MD, 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 Lean Life MD 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 period 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 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 Medmuse LLC dba Lean Life MD 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 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.
Signature*

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Should be Empty:

Lean Life Medical Intake Form

Diet and Health History

Lean Life MD Weight Management Program Policies

Incomplete Forms

No Shows

Late Shows

Refunds

Lean Life MD Disclosures Form

Disclosures

Consent For Treatment