Procedure & Expectations
I authorize New Horizon Wellness Clinics to assist me in my weight reduction efforts. I understand my treatment may involve, but is not necessarily limited to, the use of weight management medications being formulated by a compounding pharmacy that meets national standards for safety. I acknowledge that depending on my treatment plan, I might be medicated at doses higher or lower than current dosage indicated in the medication’s labeling. I have read and understand my care team’s statements that follow:
- All prescription medication has labeling determined between its manufacturer and the U.S. Food and Drug Administration. This labeling contains, among other things, suggestions for use. Weight-management medication labeling suggestions are generally based on longer or shorter studies using the dosage indicated on the label.
- As a provider, I am not required to use the medication as the labeling suggests, but I do use the labeling as a source of information along with my own experience, the experience of my colleagues, and recent studies published.
- I consent to having injections of compounded medication is not FDA approved. I realize the pharmacy is an FDA-approved 503-A or 503-B pharmacy.
I understand it is my responsibility to follow the instructions carefully and to report to the provider treating me for my weight any significant medical problems that I think may be related to my weightcontrol program, as soon as reasonably possible. Also, I will notify the provider of all medication I am taking, including anti-depressant medications and herbal supplements. I understand the purpose of this treatment is to assist me in my desire to decrease my body weight and to maintain this weight loss. I understand that my continuing to receive the weight-management medication will be dependent on my progress in weight reduction and adherence to the treatment plan. I understand that any medical treatment may involve risks as well as the proposed benefits. Please see Risk sections below. I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances made to me that the program will be successful. I also understand that obesity may be a chronic, life-long condition that may require drastic changes in eating habits and permanent changes in behavior to be treated successfully. I understand that failing to show up for an appointment I have scheduled, without calling or contacting New Horizon Wellness Clinics 24-hours ahead of time, represents a disruption to operation of the clinic. Failure to show up (“No Show”) for a pre-appointed initial or follow-up visit, or failure to cancel as least one full business day prior to a scheduled visit may result in a fee. Due to the titration regimen of this medication, periods of longer than 2 weeks without taking medication as outlines in treatment plan, will mean that clients will require re-dosing. An additional fee and a new initial intake appointment will need to be made for any clients missing more than 2 consecutive treatment weeks. I have read and fully understand this consent form and “no show” policy. I have had all of my questions answered to my complete satisfaction. I have been given ample time to carefully read and understand this form.
Risks of Proposed Treatment
I understand this authorization is given with the knowledge that the use of the weight-management medication for lower or higher doses than those indicated on the medication label and for individuals that may not meet manufacturer’s criteria involves some risk and hazard. The more common include: nausea, vomiting, skin site reactions, abdominal pain, constipation, diarrhea, fatigue, and headaches. Less common but more serious risks are anaphylaxis reactions to the medication or any of its components, kidney injury, gallbladder diseases, or pancreatitis. These and other possible risks could on occasion be serious or fatal. I understand that any medical treatment may involve risks as well as the proposed benefits. I also understand that there are certain health risks associated with remaining overweight or obese. Risks associated with remaining overweight are tendencies to have high and increasing higher blood pressure, diabetes, heart attack and heart disease, arthritis of the joints including hips, knees, feet and back, sleep apnea, and sudden death. I understand that these risks may be modest if I am not significantly overweight, but will increase with additional weight gain. I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances made to me that the program will be successful. I also understand that obesity may be a chronic, lifelong condition that may require drastic changes in eating habits and permanent changes in behavior to be treated successfully.
***Anecdotally there is reports & patient feedback identifying diminished alcohol tolerance while on semaglutide. Reports of drastically diminished alcohol tolerance have been shared. Therefore we advise thoughtfully reconsidering driving or operating heavy machinery after any alcohol consumption while on semaglutide. It can induce nausea and vomiting with alcohol consumption in some individuals. ***
CONTRAINDICATIONS
I understand that I will be determined ineligible to receive compounded semaglutide injections with New Horizon Wellness Clinics if I am less than 18 years old, pregnant, breastfeeding, trying to become pregnant, have Type 1 diabetes, diabetic ketoacidosis, if I have demonstrated an allergy to semaglutide or other GLP-1 RAs in the past, if I have a personal or family history of medullary thyroid carcinoma, a history of multiple endocrine neoplasia syndrome, or a history of pancreatitis. I understand that my medical history will be reviewed and discussed with a provider and I may be determined to be ineligible based on the findings for reasons that are at the discretion of the provider assessment.
NO GUARANTEES
I understand that while this program is designed to help with weight reduction, much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful
PHOTOGRAPHS
I consent to have my pictures and/or videos taken and stored in this clinic system. I give permission for photographs to be taken of all sites treated, which will be used to document my medical record. I also give permission for the photographs taken to be used for illustrations of scientific papers or use in educational/training lectures. I understand my name shall not be used in any publication.
COMMUNICATION
I consent to email, text, and phone communications related to post-procedure care and follow-ups.
CONSENT
I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained, or any questions have not been answered to my complete satisfaction. I acknowledge that I have been given time to completely read and understand this form, as well as discuss with my healthcare providers the risks associated with the proposed treatment and other treatments not involving weight-management medications. I do not have any of the contraindications listed above, and I have been forthcoming. Payment is due in full at the time of service and is non-refundable. I understand that this procedure is completely elective and not covered by insurance. Any expenses that may be incurred for the medical care I elect to receive outside of this office for reasons such as, but not limited to, dissatisfaction with my treatment outcome will be my sole financial responsibility. I have received aftercare instructions and agree to follow them, as this will maximize the likelihood of any complications or side effects. I release New Horizon Wellness Clinics and its practitioners of any liability associated with this procedure. I understand that this form of semaglutide is prepared by a nationally reputable compounding pharmacy. No guarantees are made as to the results of this treatment. Multiple treatments may be, and frequently are, necessary to achieve optimal/desired results. My signing of this consent is completely voluntary.
