Semaglutide | Beauty Esthetics By Diana Sanchez

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SEMAGLUTIDE / TIRZEPATIDE TREATMENT

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In case of emergency, please contact:

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Please check all that apply to you. VERY IMPORTANT:AcneHeart conditionSeborrheaImmune disordersHepatitisLupusAsthmaHerpesPacemakerArthritisHirsutismPhotosensitivityAutoimmune DiseaseHIV/AIDSPolycystic OvariesBlood disorderHypo/Hyper PigmentationPoor Blood CirculationsCancerHysterectomyVaricose VeinsBreathing Problems/ DiseaseInsomniaPsoriasisFever blistersIrregular PeriodsShinglesDiabetesLow/ High Blood PressureThyroid ImbalanceEczema/RashesMenopauseVitiligoEpilepsyMetal bone pins/platesWarts

Are you under the care of a doctor at this time? *YesNo

List everything you are currently taking:

Prescription Medications – Concentration – Frequency – Condition Being Treated

Over-the-counter medications – Concentration – Frequency – Disease being treated

Vitamins and other supplements – Strength – Frequency – Condition to be treated

List any other medical conditions you have (not listed above):

List of all surgical procedures you have had with approximate dates:

Is there anything else you would like the provider to know?

Medical Consent *

I agree that all of the above medical information is true and complete. I agree with the privacy policy and general conditions.

SEMAGLUTIDE INFORMED CONSENT

Semaglutide is an injectable prescription medication used for adults who are obese or overweight and/or related medical problems to help them lose weight and keep it off. Semaglutide is 94% similar to natural human GLP-1, acts as a physiological regulator of appetite and therefore reduces food intake by reducing the feeling of hunger and increasing the feeling of fullness/satiety.

Semaglutide should not be used with other products containing semaglutide or other GLP-1 receptor agonist medications. It is not known if this medication is safe and effective when taken with other prescription, over-the-counter, or herbal weight-loss products.

For long-term success, treatment should be combined with lifestyle changes, including nutritional, exercise, and behavioral habits.

Since each human being is unique, we cannot guarantee any specific results from treatment with Semaglutide.

Write your initials to indicate that you have been informed of:

I understand that as part of this program I will be required to complete a medical history and 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 beginning. *

I agree that I am and will be under the care of my primary medical provider for all other conditions. I understand that medical providers who administer Semaglutide cannot replace my regular primary care physician. *

I understand that there may be risks involved, as there are with all medications. *

CONTRAINDICATIONS

I understand that if I have any of the following, I should not receive semaglutide injections:

Diabetic retinopathy
Multiple endocrine neoplasia type 2
Low blood sugar
Family history of thyroid carcinoma
Decreased kidney function
Nephropathy
Pancreatitis
Allergy to semaglutide
Medullary thyroid cancer

COMMON SIDE EFFECTS

Nausea
Stomach (abdomen) pain
Diarrhea
Headache
Vomiting
Tiredness (fatigue)
Constipation

SERIOUS SIDE EFFECTS

– Inflammation of the pancreas (pancreatitis):

Stop using semaglutide and call your healthcare provider right away if you have severe pain in your stomach (abdomen) area that does not go away, with or without vomiting. You may feel the pain from your abdomen to your back.

Gallbladder problems: can cause gallbladder problems, including gallstones.

– Kidney problems (kidney failure):

Diarrhea and vomiting can cause dehydration, which can worsen kidney problems. It is important that you drink fluids to help reduce the chance of dehydration.

– Allergic reactions:

Stop using semaglutide and get medical help right away if you have any symptoms of a serious allergic reaction, such as swelling of your face, lips, tongue, or throat, problems breathing or swallowing, severe rash or itching, fainting, or dizziness. . or have a fast heartbeat.

. Incrise of cardiac frecuency:

Semaglutide may increase your heart rate while you are at rest. Tell your healthcare provider if you feel your heart racing or pounding in your chest that lasts for several minutes.

– Depression or suicidal thoughts:

You should pay attention to any mental changes, especially sudden changes in your mood, behavior, thoughts, or feelings. Call your healthcare provider right away if you have new, worse, or worrying mental changes.

RAPID WEIGHT LOSS CAN CAUSE SERIOUS HEALTH PROBLEMS. RAPID WEIGHT LOSS IS LOSS OF MORE THAN 1.5 POUNDS TO 2 POUNDS PER WEEK OR WEIGHT LOSS OF MORE THAN 1 PERCENT OF BODY WEIGHT PER WEEK AFTER THE SECOND WEEK OF PARTICIPATION IN A WEIGHT LOSS PROGRAM.

I understand that results may vary, and I understand that any request for a full or partial refund will NOT be accepted. *

I have read and understand all of the above statements and conditions and have been informed of the possible side effects and risks that may be associated with the injections. *

I fully understand what I am signing and hereby request and consent to weight loss treatment with Semaglutide. I have disclosed my complete medical history and have been informed of the benefits, side effects and/or possible rare adverse reactions of various treatments, including semaglutide. *

By signing below, I request and consent to the subcutaneous administration of semaglutide injections for the purpose of weight loss. *

PHOTO AND VIDEO AUTHORIZATION

I would like your permission to use these photos for advertising purposes. For example: portfolios, online and print ads, etc. Your consent is required in this regard. Please circle and indicate with your signature whether or not you want your photos to be used in advertising.

We also like to tag our clients in the photos used on our Instagram profile!

Please indicate whether or not you would like to allow this below:

Feel free to use them. *

Please tag me on Instagram. *