I request and consent to injections of Semaglutide/Tirzepatide and strict dietary restrictions for the purpose of losing weight. I fully understand this will be administered and monitored by the medical providers at Collective Aesthetics.

I understand that as part of the program, I will receive a limited physical exam and orientation, and will be instructed on how to administer the injections myself or arrange for assistance. Initial blood tests may be performed to rule out any conditions that would disqualify me from the program or require prior treatment. I agree to report any problems immediately to the medical provider during the treatment program.

After lab work is completed, a physical examination is conducted, typically via telehealth, and treatment begins. At this stage, refunds will not be issued due to scheduling conflicts, missed doses, or unsatisfactory results. If blood work is required, it will be performed by a licensed lab, and the associated fee will be added to your initial visit fee.

I further understand that there are risks involved with all medications and that non-compliance with dosage recommendations and dietary restrictions could increase risks and alter results. Product information is available upon request. I agree that I am, and will be, under the care of another medical provider for all other conditions. Collective Aesthetics works in conjunction with, but cannot replace, regular primary care physicians or specialists. 

At Collective Aesthetics, we are dedicated to helping our patients achieve and sustain health and wellness through natural and preventative methods. As our services focus on these holistic approaches, they are typically not covered by insurance. This includes our weight loss program, which is seldom eligible for insurance reimbursement. Therefore, we do not accept or bill insurance for this program.

I have read and understand all of the above and have been informed of potential side effects and risks associated with Semaglutide injections. I fully understand what I am signing and hereby request and consent to weight-loss treatment using injections of Semaglutide. I have disclosed my full medical history and have been physically examined by my health care practitioner. I am aware of the common risks, benefits, side effects, and adverse reactions of Semaglutide, and I have had full opportunity to ask any questions. I understand that results may vary and once I have begun the protocol, I am committed to seeing it through.

• There are several special warnings and precautions for the use of Semaglutide/Tirzepatide, including warnings on pancreatitis, cholelithiasis and cholecystitis, thyroid disease, heart rate, dehydration, and hypoglycemia in people with type 2 diabetes.
• Thyroid adverse events: Semaglutide/Tirzepatide should be used with caution in patients with thyroid disease. A higher rate of cholelithiasis and cholecystitis (gallstone and gallbladder disease) has been observed. Patients should be aware of symptoms of cholelithiasis and cholecystitis.
• Dehydration: Signs and symptoms of dehydration, including renal impairment and acute renal failure, have been reported. Patients should take precautions to avoid fluid depletion.
• Heart rate: Patients should be aware of symptoms of increased heart rate.
• Pancreatitis: If pancreatitis is suspected, Semaglutide/Tirzepatide should be discontinued.
• Thyroid C-cell tumors: Semaglutide/Tirzepatide may cause thyroid C-cell tumors in rodents. The human relevance is unknown. Patients should be aware of symptoms of thyroid tumors.
• Gastroparesis: Patients should be advised of the risk of gastroparesis due to delayed gastric emptying.
• Common side effects: Nausea, constipation, decreased appetite, dizziness, hypoglycemia, vomiting, dyspepsia, abdominal pain, diarrhea, headache, fatigue, increased lipase.
• Risks include but are not limited to: Dysgeusia, dry mouth, insomnia, asthenia, burping, constipation, diarrhea, dizziness, dry mouth, gallbladder disorders, gastrointestinal discomfort, gastrointestinal disorders, insomnia, nausea, vomiting, hypoglycemia, dyspepsia, gastritis, gastroesophageal reflux disease, flatulence, eructation, upper abdomen pain, abdomen distension, cholelithiasis, injection site reactions, fatigue, increased lipase, and increased amylase.
• Uncommon risks: Malaise, pancreatitis, tachycardia, urticaria.
• Rare risks: Renal impairment, allergic reaction, anaphylaxis.

Potential blood tests:

1. Full blood count
2. Liver function test
3. Kidney function tests
4. 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