Berzin Aesthetics - GLP-1 Intake

GLP-1 Intake

Informed Consent Form
Name*

First NameLast Name
Age*
Date of Birth*

MonthDayYear
Date
MaleFemale
Email*
example@example.com
Phone Number*
Format: (000) 000-0000.
Treatment Information

You have elected to receive Semaglutide (GLP-1 receptor agonist) therapy as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management. Semaglutide helps regulate appetite and blood sugar levels and is designed for patients with a body mass index (BMI) outside a healthy range.
Are you currently taking any medications (supplements, vitamins, contraceptives, etc.)? If yes, please list them below and the reason why you're taking it.*
Have you been hospitalized in the last 12 months? If yes, please provide the date and the reason why you were admitted.*
Treatment Protocol
• This program requires a minimum of 12 sessions to achieve optimal results.
• The medication is administered once weekly via subcutaneous injection as prescribed by your provider
• Hydration is critical: You must drink at least 32 oz of water per day to minimize side effects such as nausea and bloating.
• You are required to track your weight daily and will be weighed at each weekly appointment.
• Before and after photos are required for medical records and insurance purposes. These will remain confidential unless you provide written consent for marketing use.
Patient Responsibilities
By signing below, you acknowledge that you:
- Have disclosed all relevant medical history, allergies, and current medications.
- Understand that Semaglutide is not a standalone weight loss solution and requires adherence to a healthy diet and exercise regimen.
- Will follow dietary guidelines, including consuming at least 1,000 calories per day to avoid nutritional deficiencies.
- Will notify your provider immediately if you experience any adverse reactions or worsening side effects.
Pre-Treatment Considerations
Please read and initial each item to confirm your understanding and compliance:
- I will drink at least 32 oz of water per day to reduce side effects.
- I will consume at least 1,000 calories daily to prevent excessive caloric restriction.
- I understand that certain medications or medical conditions may contraindicate Semaglutide use.
- I will avoid excessive alcohol consumption while on this medication.
- I will follow up with my provider regularly and report any side effects.
Personal or family history of medullary thyroid carcinoma (MTC)Multiple Endocrine Neoplasia Syndrome Type 2 (MEN 2)Serious allergic reaction to Semaglutide or any of its ingredientsPregnancy, planning to become pregnant in the next two months, or breastfeedingSerious allergic reaction to another GLP-1 medication (e.g., tirzepatide, liraglutide, exenatide, dulaglutide, Wegovy, Ozempic, Rybelsus, Mounjaro, Zepbound, Saxenda, Victoza, Trulicity)History of pancreatitis, gallbladder disease, or kidney problemsHistory of diabetic retinopathyHistory of depression, suicidal thoughts, or a previous suicide attemptCurrently taking medications that interact with Semaglutide
Confirmed
Potential Risks and Side Effects

Most Common Side Effects:
- Nausea – Recommend Zofran (as needed)
- Indigestion – Recommend Pepcid, Gas-X, and avoiding spicy or high-fat foods
- Bloating – Recommend increased fiber intake and hydration
- Fatigue, headache, dizziness, belching, abdominal distention
- Hypoglycemia, gastroenteritis, and mild gastrointestinal discomfort
- Injection site reactions (itching, burning, thickening of the skin)
Less Common but Serious Side Effects:
- Pancreatitis, gallbladder disease, or acute kidney failure
- Severe allergic reactions (swelling of the face, lips, tongue, throat, rapid heartbeat, difficulty breathing or swallowing, fainting, rash)
- Vision changes in diabetic patients
- Increased heart rate, depression, or suicidal thoughts
Drug Interactions and Medical Considerations
- I understand that I will not use this medication with any other product containing Semaglutide or similar GLP-1 medications.
- I acknowledge that Semaglutide may slow gastric emptying, affecting how well my body absorbs other medications.
- I will inform my provider of all medications I am taking, including dietary supplements.
- I understand that using Semaglutide with insulin, sulfonylureas, or DPP-4 inhibitors may increase my risk of low blood sugar (hypoglycemia).
Legal Disclaimer and Release of Liability

I acknowledge that this treatment is elective and not medically necessary. I understand that Berzin Aesthetics, its medical staff, and Dr. Bella Berzin make no guarantees regarding treatment results. I understand that results may vary from person to person and that multiple sessions may be required for optimal outcomes. I release Berzin Aesthetics, Dr. Bella Berzin, and affiliated staff from any liability related to the effectiveness of my treatment or potential side effects.
Treatment Acknowledgment and Consent

By signing below, I confirm that I have read and understood this consent form. I have had the opportunity to ask questions, and all my concerns have been addressed to my satisfaction. I acknowledge the risks, benefits, and limitations of my selected treatment(s) and consent to proceed.
Patient Acceptance
Name*

First NameLast Name
Signature*
Medical Director - Treatment Plan Approval

Our Medical Director is currently reviewing your treatment plan for approval. If there are any medical concerns or contraindications, we will contact you for clarification. You will receive confirmation upon approval.
Should be Empty:

GLP-1 Intake

Treatment Information

Legal Disclaimer and Release of Liability

Treatment Acknowledgment and Consent

Patient Acceptance

Medical Director - Treatment Plan Approval