By my signature below I do willingly request and consent to semaglutide, tirzepatide, L-Carnitine, and/or B-12 injections (if selected) by New Age Aesthetics and Wellness. While proven successful in weight loss, I understand that there is no warrant or guarantee of results from using either semaglutide or tirzepatide weekly injections.

1. I understand that as part of this program I will be required to complete a Medical History and meet with a Medical Provider to determine my candidacy. I understand that initial blood tests may be required to rule out any conditions that would disqualify me from the program or require any prior treatment before starting the program. I agree to immediately report any problems that might occur to my Medical Provider or the staff of New Age Aesthetics and Wellness, as well as my primary care provider (PCP) during the treatment program.
2. I understand that there could be risks involved, as there are with all medications. Failure to comply with the dosage recommendations and dietary restrictions could alter weight loss results.
3. I agree that I am, and will be, under the care of my PCP for all other medical conditions.
4. I understand that treatments for weight loss are rarely covered by insurance companies. We do not accept or bill insurance for this program.
5. I understand that medication is ordered on a per patient basis and that I am to pay in advance for the full month of injections. At any point I can choose to discontinue the program.
6. 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, I accept full liability for any consequence that may arise therefrom.
7. I acknowledge that Semaglutide and Tirzepatide are in high demand throughout the country and despite New Age Aesthetics and Wellness having multiple U.S. based suppliers, it's possible that the medication may not be available.
8. SEMAGLUTIDE AND TIRZEPATIDE CONTRAINDICATIONS: I UNDERSTAND THAT IF I CURRENTLY HAVE ANY OF THE FOLLOWING CONDITIONS I SHOULD NOT TAKE SEMAGLUTIDE OR TIRZEPATIDE INJECTIONS: diabetic retinopathy (a type of damage to the eye from diabetes), low blood sugar/hypoglycemia, decreased kidney function, pancreatitis, medullary thyroid cancer, multiple endocrine neoplasia type 2, family history of medullary thyroid carcinoma and/or kidney disease with likely reduction in kidney function.
9. 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 and Tirzepatide. I fully understand what I am signing and hereby request and consent to this weight-loss treatment.