Wegovy/Ozempic/Semaglutide Weight Loss Injection Form

Please fill in the form below

Full Name *

Email *

Sex

Male

Female

Other

Date of birth *

Phone *

Address: *

City *

State *

Country

Postal code *

Emergency Contact name and Phone Number: *

Physician Name and Phone:

How did you hear about us? *

Medical History

Please describe the reaction you experienced:

Taking any medications, currently? *

Yes

If yes, please list it here

Female Clients

Are you pregnant or trying to become pregnant?

Yes

If pregnant what week of pregnancy are you in?

Are you breastfeeding?

Yes

Contraindications

I certify that I do not have any of the following contraindications. *

• diabetic retinopathy • low blood sugar of unknow origin • decreased kidney function • pancreatitis • medullary thyroid cancer • multiple endocrine neoplasia type 2 • family history of medullary thyroid carcinoma • kidney disease with likely reduction in kidney function

Patient Agreement

I agree to the following please initial each sentence: *

I am responsible for my medicines. I will not share, sell, or trade my medicine. I will not take anyone else’s medicine.

I will not increase my medicine until I speak with my doctor or nurse.

My medicine may not be replaced if it is lost or stolen.

I will keep all appointments set up by my provider.

I understand the contraindications and the provider has answered all asked questions.

Informed Consent

I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform Dr. Taylor and Yvonne Alvarez RN of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures. I agree to receive treatment from Dr. Taylor and or Yvonne Alvarez RN.

If I break any of the rules, or if my provider decides that this treatment is not benefiting me or helping me, this medicine may be stopped by my provider. I have talked about this agreement with my provider, and I understand the above rules.

Please Type Your Full Name as Signature of agreement of Informed Consent and certification statement. *

Date *

Medical Director - Dr. Frank DiMotta, Dr. Jill Sohayda, and Dr. Jeff McKinley