By signing Below, I acknowledge that I have provided complete and accurate information and understand that it will be used to assess my suitability for any treatment. I understand that it is my responsibility to inform the therapist of any changes to my medical history Dr skincare routine. I agree to waive all liabilities for any injury or damages incurred due to misrepresentation of my health history.

Payment Policy:
• We require payment for all services at the time of rendering.
• Accepted payment methods include cash, VISA, Mastercard, or AMEX.

Cancellation Policy:
• Cancellations must be made 2 days before your appointment.
• Cancellations made within 1 day will incur a 50% charge.

Refund Policy:
• All sales are final and non-refundable.
• Dispensary and wellness products must be paid for at the time of service, with no refunds available.

We adhere to HIPAA guidelines to protect your privacy and ensure you have access to your medical information. This notification outlines how your medical data may be used and shared, as well as how you can access it. Please read it carefully. As per the Health Insurance Portability and Accountability Act (HIPAA) of July 1, 1997, we are legally obligated to safeguard your protected health information (PHI). Your privacy rights are respected by our office. Information related to your therapy sessions with us is strictly confidential and is only shared with your doctor and emergency contact. For any external requests for your information, we require your signed authorization. Any other use of your protected health information will only be done with your consent, which you can revoke at any time. In legal matters, your attorney can access your files with your written consent. If requested by the opposing party's attorney, we must comply with a subpoena for your records. EstheticFit will not use or disclose your PHI for marketing purposes without your explicit consent.

Disclosure: We may use or disclose your PHI without your consent or authorization
when required by law. Patient Rights Notice of Privacy Policy: A patient/client may request restrictions on certain uses and disclosure of the protected information. You have the right to receive confidential communication of protected health information.

By signing below, I acknowledge that I have provided complete and accurate information and understand that it will be used to assess my suitability for any treatment. I understand that it is my responsibility to inform the therapist of any changes to my medical history or skincare routine. I agree to waive all liabilities of Esthetic Fit or any injury or damages incurred due to misrepresentation of my health history.

I hereby give my consent to taking Tirzepatide or Semaglutide injections as prescribed by my healthcare provider. I understand that these medications are a human-based glucagon-like peptide-1 receptor agonist used to manage weight gain and diabetes. I hereby acknowledge that I have been informed of the correct method of administering my injections and the dosage. I hereby confirm that I will not take this medication if I am pregnant, breastfeeding or planning to conceive, have a personal or family history of Medullary Thyroid Carcinoma (Thyroid Cancer) or Multiple Endocrine Neoplasia Syndrome Type 2 (MEN2), a history of pancreatitis, kidney failure/disease, liver failure/disease, or gastrointestinal issues, allergic to Semaglutide or Tirzepatide or another GLP-1 agonists or you have other undisclosed allergies, diabetic, have retinopathy or take medication to lower blood sugar without consulting with an endocrinologist.

Possible side effects: nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dyspepsia, dizziness, abdominal distension, belching, hypoglycemia, flatulence, gastroenteritis, and gastroesophageal reflux disease. Common injection site reactions include itching, burning, and skin thickening. In case of a serious allergic reaction, with rash, itching, facial, tongue or throat swelling, and anaphylaxis, seek immediate medical assistance.

Possible drug interactions: anti-diabetic agents, particularly insulin and sulfonylureas, can lead to an increased risk of low blood sugar. Additionally, do not combine with other GLP-1 agonist medicines. Inform your provider of any medications that may lower blood sugar.

I hereby acknowledge that semaglutide and tirzepatide are part of a comprehensive lifestyle approach that includes a healthy diet and exercise, and regular follow-up visits to adjust dosages are necessary for optimal results.

I hereby wish to self-administer semaglutide or tirzepatide injections as part of my weight loss treatment. I hereby understand that my injections are subcutaneous and have been educated on how they should be administered. I hereby understand that it is my responsibility to refrigerate the medication vial upon receiving.

I hereby understand that while self-administering my injections, there are potential risks. I understand that these potential risks include, but are not limited to, bruising, redness, bleeding temporary increase in pain, inflammation, infection, allergic reaction, numbness, and muscle weakness at the injection site. I hereby confirm that, should I experience any of the above, I will call and consult the provider immediately. I acknowledge responsibility for the immediate storage of this medication upon receipt. I hereby understand they should be kept out of reach of children and pets.

I hereby understand that my needles should never be thrown away loosely in the trash. They will need to be disposed of in a sharps container, or in a strong plastic container with a lid. If I choose to use a plastic container, I am aware that I need to fill it 3/4 full, seal it with the lid, tape it closed, and mark "DO NOT RECYCLE" clearly on the container. Once completed, I understand that I should place the container in a dark plastic trash bag, seal the bag closed, and place it in my trash bin for normal pickup.

I understand that I am taking full responsibility for any consequences that may result from the self-administration of my injections.

By signing below, I confirm that I have been fully informed of the potential risks, benefits, and complications and I voluntarily agree to commence therapy on this medication. I have had the opportunity to raise inquiries, and all my concerns have been addressed to my satisfaction. I release the provider and establishment from any liability or claims arising from my treatment.

I hereby understand and acknowledge that the practitioner providing services has opted not to carry malpractice insurance as allowed under Florida law. By signing this waiver, I voluntarily waive my right to file legal action or pursue any legal claims for any services rendered by the practitioner and the facility referenced herein. I acknowledge that I have been informed of this decision and agree to this waiver of liability freely and without coercion.