Onlinse Consent for Ozempic

Online Consent Form for Compounded Ozempic (Semaglutide)
Patient Information
Name*
Date of Birth*

MonthDayYear
Gender*
Email
example@example.com
Phone Number*
Format: (000) 000-0000.
Address

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Parent/Guardian or Emergency Contact Details
Contact Person Name*
Primary Phone Number*
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Secondary Phone Number
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Medical Data
Doctor/Clinic’s Name

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Do you have a drug allergy or Food allergy? *
Please let us know to which drug or food allergies you may have...
Acknowledgment, Authorization and Waiver
TELEHEALTH CONSENT FORM

TELEHEALTH SERVICES Telehealth involves the use of electronic information and communication technologies to deliver health care services to patients who are located at a different site than the provider. This includes, but is not limited to, video conferencing, audio communication, and text messaging.

POTENTIAL BENEFITS

· Increased accessibility to care

· Reduced wait times

· Convenience

POTENTIAL RISKS

· Limited physical examination

· Technical issues, such as connection problems

· Security breaches

CONSENT I understand the following:

· The laws protecting the confidentiality of medical information also apply to telehealth.

· I have the right to withhold or withdraw my consent to the use of telehealth services at any time.

· The care may not be as complete as a face-to-face service.

· I must take precautions to ensure the privacy of my environment during telehealth consultations.
Date Signed

MonthDayYear
Patient/Parent/Guardian Signature*

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Personal Medical/ Family History
Heart disease (such as heart attack, rheumatic fever, irregular heartbeat, angina, heart murmur, chest pain)Diseases of the arteriesHigh blood cholesterolAnemia of other blood disorders for example Sickle Cell disease, ThalassemiaHistory of dizziness, seizures, or strokeMedullary thyroid cancerAny thyroid disease/ problemsParathyroid problems or Adrenal gland problemsDiabetes or abnormal blood-sugar testsPhlebitis (inflammation of a vein)Deep vein thrombosis/blood clot in the leg (DVT) or PE (pulmonary embolism)Gallstones or any gallbladder disease (including Jaundice)High blood pressureSevere reflux (Hypertension)Any breathing problems (such as asthma, COPD, bronchitis)Infective endocarditisKidney problems includingChronic Kidney disease (CKD)Pancreas/ digestion problems (including acute or chronic pancreatitis)Stomach/ duodenum ulcerLiver problems (including hepatitis, liver failure, fatty liver, alcoholic liver disease)Any neurological problems (including Parkinson Disease)Severe stomach/gut problems (incl. Inflammatory bowel disease: Crohn’s disease or Ulcerative Colitis)Irritable bowel syndrome (ibs)Jaundice or gall bladder problemsSkin conditions eating disorder (such as anorexia or bulimia)Mental health problems (Including personality disorder, psychosis, diagnosis of depression)Self-diagnosis of depression, low mood, nervous or emotional problemsSubstance abuse (including alcohol or drugs)Any allergies (including food or drugs)Do any of the discussed contraindications apply to you?
Patient Initials
Heart disease under age 50Strokes under age 50High blood pressureElevated cholesterolDiabetesAsthma or high feverSin allergiesCongenital heart disease (existing at birth but not hereditary)Heart surgeryRed blood cell disorders (ex, Sickle Cell, Thalassemia, and Anemia)GlaucomaKidney DiseaseObesity (20 or more pounds overweight)Leukemia or cancer under age 60
Patient Initials
Consent Form for GLP-1 and Weight Reduction Safety Disclosure
This document is intended to serve as a confirmation of informed consent for Compounded Semaglutide.

Compounded Semaglutide medication is a human-based glucagon-like peptide-1. Receptor agonist prescribed as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) that is considered outside a healthy range.

While using Compounded semaglutide medication, it is highly recommended that you:
- Eat a fibrous diet: Focus on fruits and vegetables that are high in fiber.
- Eat small high protein meals and digestion is slowed down while on this medication.
- Avoid foods high in fat as they take longer to digest.
- Limit alcohol intake as this medication can lower blood pressure.
- Drink at least 64 oz of water a day to avoid constipation.
Do not take this medication if:
- You have a personal or family history of medullary thyroid carcinoma (Thyroid Cancer)
- Multiple Endocrine Neoplasia syndrome type 2.
- You are pregnant or plan to become pregnant while taking this medicine.
- You are diabetic and/or taking any medications related to lowering your blood sugar levels without speaking with your endocrinologist.
- Specifically, if you are prescribed Insulin because the combination may increase your risk of hypoglycemia (low blood sugar) and dosage adjustments by your provider may be necessary.
- You have a history of Pancreatis.
- You are allergic to any GLP-1 medication agonist such as Adlyxin, Byetta, Bydureon, Ozempic, Rybelsus, Trulicity, Victoza, Wegovy.
- If you have other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details. Before using this medication, tell your doctor/pharmacist your medical history.
Labs

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Patient Initials
Weight Reduction and Safety Disclosure

I understand that weight loss medication DOES NOT guarantee weight loss, especially if I do not use the medication along with a healthy diet and exercise. I DO NOT hold Bueno Pharmacy/Bueno Clinic responsible for lack of weight loss success. I understand that weight loss treatment is only one part of my weight loss plan to help me reach my goals. I understand that I also need a reduced calorie diet and increased physical activity for chronic weight management. I have been informed that weight loss prescriptions are contraindicated in pregnancy or nursing

I understand that weight loss prescriptions can cause side effects such as: facial swelling, feeling faint or dizzy, trouble breathing or swallowing, rapid heartbeat or severe rash and itching. I acknowledge the following risks of taking weight loss medication including but not limited to: Drop in blood sugar levels, diabetic retinopathy complications for those with diabetes, suicidal thoughts or behavior and risk of thyroid tumors, pancreatitis, acute gallbladder disease, renal impairment, and other hypersensitive reactions.

Terms of Use and Supplemental Services Disclosure I understand that this process may be delayed if I provide insufficient medical history or if additional detail is requested by my medical provider. At Bueno Pharmacy/ Bueno Clinic only prescribe FDA-approved medications and follows evidence-based medical guidelines. I have been informed that it is my responsibility to handle prescription medication with care and store it in a safe environment.

I understand that I have full monetary responsibility for any services rendered at Bueno Pharmacy/ Bueno Clinic.
Patient Name
Patient Signature

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Date

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Online Consent Form for Compounded Ozempic (Semaglutide)

Patient Information

Parent/Guardian or Emergency Contact Details

Medical Data

Acknowledgment, Authorization and Waiver

Personal Medical/ Family History

Consent Form for GLP-1 and Weight Reduction Safety Disclosure