Semaglutide Infusion Injection Consent Form

Allure Infusion Semaglutide Injection Consent Form

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ACKNOWLEDGEMENT

Semaglutide 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 semaglutide, it is highly recommended you: eat a fibrous diet; eat small high protein meals, as 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 your blood pressure; drink water.

I am electing to have semaglutide injected into my body, and understand I can stop receiving the injection at any time.

I understand a complimentary visit with a provider - DO or Nurse Practitioner - might be required prior to the administration of semaglutide.



RISKS

Do not take semaglutide 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 Pancreatitis.
  • You are allergic to BPC-157, Semaglutide or any other GLP-1 agonist such as: Adlyxin®, Byeta®, 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.


Possible drug interactions: Anti-diabetic agents, specifically: Insulin and Sulfonylureas (e.g., glyburide, glipizide, glimepiride, tolbutamide) due to the increased risk of hypoglycemia (low blood sugar). Do not take with other GLP-1 agonist medicines such as: Adlyxin®, Byeta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy® (THIS IS NOT AN ALL-INCLUSIVE LIST). Other medications used in diabetes, please tell your provider about any medications that may lower your blood sugar.

Possible side effects: Nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dyspepsia, dizziness, abdominal distension, belching, hypoglycemia, flatulence, gastroenteritis, and gastroesophageal reflux disease. Subcutaneous Injections: common injection site reactions characterized by itching, burning at site of administration with or without thickening of the skin(welling). If you notice other side effects not listed above, contact your doctor or pharmacist. A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing. Report adverse side effects to your doctor or pharmacist. In the event of any emergency, call 911 immediately.

I answered / will answer the Medical Questionnaire truthfully and to the best of my knowledge. I release Allure Health and its staff of all responsibility should I falsify the information provided or refrain from disclosing certain diagnoses.

PAYMENT

Payment is due at the time of service. There has been no representation that this procedure is covered under my health insurance plan or that I can/should seek such reimbursement. I agree to pay the full cost of the service regardless of injection cancellation or if the infusion is stopped at any time prior to completion at the discretion of the registered nurse.

I understand that I am responsible for the full cost of the injection(s) and agree to pay.

The procedure(s) and this consent form have been adequately explained to me.

I certify that I am not pregnant. If I am uncertain of a pregnancy, I can request a urine pregnancy test at this office, and will be responsible for the full costs associated with such a test. I certify that I am not intoxicated on alcohol or any illicit drugs.

I authorize and consent to the performance of the injection(s). This consent is valid unless rescinded, which I can do at any time.

Consent*
Patient / Legal Representation*
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