Semaglutide/ Ozempic Medical History & Consent Form

Name

First Name

Last Name

Email*

Phone

(###)

###

####

Address

Date of Birth

YYYY

Consultation Date

YYYY

Gender

Male

Female

Are you suffering from a medical condition, illness, or injury?

Yes

What is the reason you want to try Semaglutide?

What is the reason you want to lose weight?

How long has your weight been a problem?

Are you currently at your heaviest weight?

Yes

If no, how much did you weigh at your heaviest weight?

What methods have you previously tried to lose weight?

Are you scared of needles/needle phobic/faint easily when you have blood taken?

Yes

Women only. Answer the following. (Check questions which you answer yes, leave others blank if no)

Are you trying for pregnancy or planning pregnancy in the near future?

Are you or could you be pregnant?

Are you breastfeeding?

Are you on any type of hormone replacement?

Are you on birth control?

List any prescription medications you are now taking.

Are you on any blood thinners?

List any self prescribed medications, dietary supplements, or vitamins you are now taking.

List hospitalisations, including dates of and reasons for hospitalization (including surgeries)

List any drug or seasonal allergies.

Comments:

Familial Diseases (Family history) Have you or your blood relatives had any of the following (include grandparents, aunts and uncles, but exclude cousins, relatives by marriage and half-relatives)?

Consent to Ozempic Treatment

Before you choose to use the services of practitioner: please read the following information FULLY AND CAREFULLY:

Consent to Ozempic Treatment

Before you choose to use the services of practitioner: please read the following information FULLY AND CAREFULLY: Why Ozempic injections? The main benefits may include: 1. Ozempic (Semaglutide) is 94% similar to natural human GLP-1 and therefore acts as a physiological regulator of appetite and thereby reducing food intake by reducing feelings of hunger and increasing feelings of fullness/satiety. The exact underlying mechanism of action is 2. Ozempic is a newly licensed medication indicated for the treatment of type-2 diabetes. It is currently undergoing clinical trials to gain a license for the treatment of obesity. In the meantime, your medical practitioner may prescribe this medication for you 'off-label' 3. For long term success the treatment needs to be combined with lifestyle changes including nutritional, exercise and behavioral habits. 4. Weight loss can lead to secondary benefits by improving weight loss related health problems such as cardiovascular risk factors (including hypertension, blood glucose levels and waist circumference) and physical health-related Quality of Life. I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent. Since every human being is unique, we cannot guarantee any specific result from Ozempic treatment. Medication and or medical conditions may have a negative impact on the outcomes as well as lifestyle factors. Treatment should be discontinued after 12 weeks if the patient has not lost at least 5% of their initial body weight. Patients need to follow the instructions carefully as provided separately in the patient instruction sheet. Patients must agree to notify their practitioner of any contraindications or side effects of the treatment. We will write to your GP to notify them of details of the program and any blood results (if completed) It is essential to engage with the 2 weekly telephone review and monthly face-to-face reviews with your doctor throughout the treatment program. HEALTH CONCERNS: If you suffer from a medical or pathological condition, you need to consult with an appropriate healthcare provider such as your GP or Consultant. If you are under the care of another healthcare provider, it is important that you inform your other healthcare providers of your use of Ozempic. If you are using medications of any kind, you are required to alert us. Note: If you have any physical or emotional reaction to Ozempic treatment, discontinue use immediately, and contact your PRACTITIONER to ascertain if the reaction is adverse or an indication of the natural course of the body's adjustment to the treatment. Laboratory testing may be done to any patient identified at risk to determine areas of dysfunction, not to diagnose or treat. Potential blood tests: • Full blood count • Liver function test • Kidney Function Tests • Cholesterol levels, HbA1c, Glucose Patient groups who may require blood test monitoring at additional cost: (Age 50 or above) • High blood pressure • Pre-Diabetics • Any significant medical problem

I confirm that I accept the extra blood tests with further monitoring as above if required with an additional cost as specified in the Patient price list.

Initials*

COMMUNICATION: Every client is an individual, and it is not possible to determine in advance how your system will react to the treatment. It is sometimes necessary to adjust your program as we proceed. It is your responsibility to do your part by following healthy dietary guidelines, exercise your body and make necessary behavioral modifications. 1. Alternatives to Ozempic therapy are surgical procedures, oral medical treatments (including Orlistat) and / or dietary and lifestyle changes alone. 2. Several weeks to months of treatment may be required depending on your individual response. 3. If a missed dose is more than 5 days late, the missed dose should not be taken, and the next dose should be taken at the normal time. 4. It is essential to combine eating, exercise and behavioral modifications with Ozempic. 5. Ozempic should not be used in combination with another GLP-1 receptor agonist, insulin or insulin secretagogues (such as sulfonylureas) due to the risk of hypoglycaemia. 6. Upon initiation of Ozempic treatment in patients on warfarin or other coumarin derivatives more frequent monitoring of International Normalized Ratio (INR) is recommended. 7. Ozempic causes a delay of gastric emptying and has the potential to impact the absorption of concomitantly administered oral medications. Monitor for potential consequences of delayed absorption of oral medications concomitantly administered with Ozempic 8. There are several special warnings and precautions for use of Ozempic including warnings on pancreatitis, cholelithiasis and cholecystitis, thyroid disease, heart rate, dehydration and hypoglycaemia in people with type 2 diabetes. 9. Thyroid adverse events, such as goiter have been reported in particular in patients with pre-existing thyroid disease. Ozempic should therefore be used with caution in patients with thyroid disease. 10. A higher rate of cholelithiasis and cholecystitis (gallstone and gallbladder disease) has been observed in patients treated with semaglutide. Cholelithiasis and cholecystitis may lead to hospitalization and cholecystectomy (surgery to remove the gallbladder Patients should be aware of the characteristic symptoms of cholelithiasis and cholecystitis. 11. Signs and symptoms of dehydration, including renal impairment and acute renal failure, have been reported in patients treated with Semaglutide. Patients treated with semaglutide should be advised of the potential risk of dehydration in relation to gastrointestinal side effects and take precautions to avoid fluid depletion. Patients should also be aware of the symptoms of increased heart rate. 12. Acute pancreatitis has been observed with the use of Semaglutide. Patients and their carers should be told how to recognise signs and symptoms of acute pancreatitis and advised to seek immediate medical attention if symptoms develop. If pancreatitis is suspected, semaglutide should be discontinued; if acute pancreatitis is confirmed, semaglutide should not be restarted. 13. Ozempic may cause dose-dependent and Treatment-duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Ozempic causes thyroid C-cell tumors, including medullary thyroid carcinoma (cancer, MTC), in humans, as the human relevance of semaglutide-induced rodent thyroid C-cell tumors has not been determined. Patients should be aware of symptoms of thyroid tumors (such as a mass in the neck, difficulty swallowing, difficulty breathing or shortness of breath, persistent hoarseness The most common Saxenda side effects are: • Nausea • Constipation • Decreased appetite • Dizziness • Hypoglycemia • Vomiting • Dyspepsia • Abdominal pain • Diarrhea • Headache • Fatigue • Increased lipase Nausea is the most common side effect when first starting Sexenda®, but decreases over time for most people as their body gets used to the medicine. The dosing schedule is designed to reduce the likelihood of gastrointestinal symptoms. Tell your health care professional if you have any side effect that bothers you or that does not go away. Risks of Ozempic treatment include but are not limited to: a. Common or very common, reported in 5%: Dysgeusia (altered sense of taste), dry mouth, insomnia, asthenia; burping; constipation; diarrhea; dizziness; dry mouth; gallbladder disorders; gastrointestinal discomfort; gastrointestinal disorders; insomnia; nausea; vomiting, hypoglycaemia, dyspepsia, gastritis, gastro-oesophageal reflux disease, flatulence, eructation, upper abdomen pain, abdomen distension, cholelithiasis, injection site reactions, fatigue, increased lipase and increased amylase. b. Uncommon: Malaise; pancreatitis; tachycardia; urticaria c. Rare: Renal impairment, allergic reaction, anaphylaxis Do not take Ozempic if any of the below contraindications apply to you: a. Aged under 18 or above 75 b. Severe renal/kidney impairment (with eGFR of 15 or below) or a history of renal disease c. Severe hepatic/liver impairment d. Personal or family history of medullary thyroid cancer (MTC) e. Hypersensitivity to Ozempic or to any of the excipients: disodium phosphate dihydrate, propylene glycol, phenol and water for injection f. Concurrent treatment with any other products for weight management g. Weight problems related to endocrinological or eating disorders h. Concurrent insulin or sulfonylurea i. Patients on warfarin (more frequent INR monitoring required) j. Concurrent use of any medicinal products may cause weight gain k. Pregnancy, breastfeeding or trying to/planning to become pregnant. Congestive heart failure m. History of pancreatitis, gallbladder disease, inflammatory bowel disease, diabetic gastroparesis. The below drugs interact with Ozempic and treatment of Ozempic should not be used concurrently. Drug interactions: • Alogliptin • Biphasic insulin aspart • Biphasic insulin lispro • Biphasic isophane insulin • Canagliflozin • Dapagliflozin • Dulaglutide • Empagliflozin • Exenatide • Glibenclamide • Gliclazide • Glimepiride • Glipizide • Any insulin including aspart, degludec, detemir, glargine, glulisine, lispro, isophane, zinc suspension • Nateglinide • Pioglitazone • Repaglinide Saxagliptin, Sitagliptin, Vildagliptin • Tolbutamide

I am aware that other unforeseeable complications could occur. I do not expect the clinic to anticipate and or explain all risk and possible complications. I rely on them to exercise judgment during the course of treatment. I understand the risks and benefits of the treatment and have had the opportunity to have all of my questions answered.

I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. At any stage during the treatment, I have the right to request that the procedure is terminated, however accept that I will not be reimbursed once supply has commenced.

Patient Name

Practitioner Office

I declare that the info I’ve provided is accurate & complete

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Semaglutide/ Ozempic Medical History & Consent Form

Lakeland Cryo & Reshaping