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Informed Consent

(Please read to sign at appointment)

                                     INFORMED CONSENT

The operations at this location:

Services include the medical skills that involve the practice observing and palpation of the skin. The treatments are superficial and noninvasive. The treatments are done only with gentle soft hand touch. There are no deep tissue treatments offered.  The treatments are not meant to do harm, cause pain or discomfort, but are meant to promote relaxation to help improve physical health and well-being.  The treatments do not include deep tissue treatment with the use elbows, knees, feet, needles or balls. This location does not offer massage therapy, physical therapy or behavior therapy.  It does not offer cosmetic surgery, body work enhancement procedures, surgical removal of tissue, injury repair, antiaging procedures or pain management. There are no pharmaceutical medicines on site.  If further treatments are needed beyond the scope of care within this location, as a primary care board certified physician, Dr. Organ is licensed to  recognize urgent concerns and make recommendations or referral to the appropriate therapist or specialist as needed.

I have read the above information. I fully understand and agree to services on these terms. It is my choice to receive Touch treatments. I am aware of the benefits and risks of the treatments and give my consent.  I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that touch treatment is not a substitute for medical care, medical examination, or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment.

 

Name (Print)____________________________________________

Signature________________________________________

Date_____________

SEMAGLUTIDE CONSENT

SEMAGLUTIDE CONSENT:  I hereby authorize and direct Dr. Mirian Boyd Organ a Board Certified Physician to prescribe Semaglutide subcutaneous injection to me. Semaglutide is FDA approved overweight and obese individuals struggling to lose weight. I understand that this procedure is effective at reducing appetite and energy intake while delaying gastric emptying. Semaglutide is a Glucagonlike peptide-1 (GLP-1) produced by the gut. It increases insulin production, a hormone that lowers the blood sugar level while inhibiting glucagon secretion, which is a hormone that raises blood sugar. For this reason, weight loss from any one treatment is unlikely, and I understand that I will require several treatments to obtain a significant, long-term reduction in BMI and abdominal circumference. I also understand that the results of this treatment vary with each individual. I do not have a history of Medullary Thyroid Cancer, Multiple Endocrine Neoplasia, Active Eating Disorder (anorexia, bulimia, etc.)or am currently pregnant or planning to become pregnant within the next year.  I understand that I must inform the provider about changes in my medical condition, medication that I am taking and any diabetes, appetite stimulants, phentermine, kidney issues, heartburn, nausea, constipation, dehydration, peptides, human growth factor or insulin like growth factor. I acknowledge that the following points have been discussed with me: The potential benefits of the proposed procedure. The possible alternative procedures. The probability of success. Weight loss is not a guarantee with every patient. The reasonably anticipated consequences if the procedure is not performed. The possible complications/risks involved with the proposed procedures and subsequent healing. period, including, but not limited to: bruising, bleeding, infection or pain at injection site. The possible side effects include but are not limited to: nausea, vomiting, diarrhea, constipation, indigestion, hypoglycemia, dyspepsia, abdominal pain, headache, fatigue, increased lipase, flatulence, and gerd. Health Concerns If you suffer from a medical or pathological condition, you need to consult with an appropriate healthcare provider such as your primary doctor or endocrinologist or cardiologist. If you are under the care of another healthcare provider, it is important that you inform your other healthcare providers of your use of Semaglutide. Diabetes patients are recommended to seek treatment from a primary care doctor or endocrinologist. Dr. Organ does not treat or manage diabetic patients. Post-treatment instructions: I understand that it is difficult to list every undesirable effect that may result from this procedure however, I acknowledge that I am aware of the following possible risks/experiences involved with Semaglutide injection I have been informed that I need to: Drink 3 liters of water daily. Eat breakfast and lunch Skip dinner Avoid spicy food. Kidney injury due to dehydration from reduced appetite is possible due to lack of water intake. Gastrointestinal Side effectsNausea and indigestion are common in the first week of treatment. If vomiting develops then Zofran can be prescribed. Eating after sunset elevates heartburn. OTC medications for heartburn are Tums and omeprazole. Drink 3 liters of water daily and exercise three times a week to prevent constipation. Discomfort – Some discomfort, pain and/or bruising may be experienced at the injection site. Pregnancy - I deny the possibility of being pregnant at this time. I understand that the safety of the use of semaglutide during pregnancy and breastfeeding has not been studied. If I am unsure of pregnancy, I will request a pregnancy test prior to my treatment. BY By Clicking the policy button,  I CERTIFY THAT I HAVE DULY READ AND FULLY UNDERSTAND THE CONTENTS OF THIS CONSENT/PERMISSION FORM FOR SEMAGLUTIDE INJECTION USE AND THAT THE DISCLOSURES REFERRED TO HEREIN WERE MADE TO ME. I CERTIFY THAT I HAVE BEEN COUNSELED IN PRE/ POST TREATMENT INSTRUCTIONS AND HAVE BEEN GIVEN WRITTEN INSTRUCTIONS, I HAVE BEEN GIVEN THE OPPORTUNITY TO ASK QUESTIONS AND THEY HAVE BEEN ANSWERED. I HEREBY FREELY CONSENT TO SEMAGLUTIDE TREATMENTS. BY MY SIGNATURE BELOW, I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS CONSENT/PERMISSION FORM FOR SEMAGLUTIDE AND THAT THE DISCLOSURES REFERRED TO HEREIN WERE MADE TO ME. I AGREE THAT THIS FORM SUPERSEDES ANY PREVIOUS VERBAL OR WRITTEN DISCLOSURE.

Menstrual and Medical History

(Please review we will fill out and sign at appointment)

  Dr. Mirian Boyd Organ’s Women’s Day Spa

  History form

    Name _________________________________________________

    DOB_______________

   Address _______________________________________________

   City ______________________________________State __________

   Zip _____________________________ Phone____________________________

   Email ____________________________________________________________

Menstrual History (Complete as much as you can even if you are menopausal)

Age ______________   Preg___ Live biriths____         LMP_____________

Age periods started_______________  Breastfeeding history: yes or no

If your menstrual periods are regular ____________, How many days apart_____

If your menstrual periods are irregular__________, How many times a month___

How heavy is your bleeding, ____mild _____moderate______heavy (clots)

Which symptoms are associated with your periods, (before, during or after) 

     ___anger                   ____depression         ____loss of interest

     ___anxiety                 ____headaches        ____self-depreciating thoughts

     ____clotting              _____hot flashes           ___Sensitive to rejection

     ____cramping            ____heart palpitations     ___difficulty concentrating

     ____cravings              _____irritability                    ___leg swelling

     ____crying                  ____insomnia                      ____Binge eating

     ____bloating              ____Fatigue or exhaustion ____Brain fog

     ____bowel changes    ____mood swings                ____Rage

     ____Breast tenderness  ___less productive        _____Panic attacks     

    ___Back ache ____Nause/vomiting  _ ___Family is concerned _____acne

    ____Overthinking   ____ Overtalking     _____more sensitive

     Gynecological/ obstetric surgery:

         Ovaries:  yes ______               no________

         Uterus:      yes _____              No________

         Fallopian tubes:   yes_______     No_______

         Cesarean Section:  yes______     No_______

         Abdominal surgery:  yes______   No______

          Breast Surgery: yes_______         No_______

   OtherSurgeries____________________________________________________

   Hospitalizations in the last 5 years___________________________________

Allergies________________      Occupation______________________________

PMH:

Heart Dx _____      Diabetes ________    High Blood Pressure____ Strokes _____

Cancer(type)_______  Neuropathy______ Kidney Dx_______

Gastrointestinal Dx_______ Arthritis______ Anemia______

Musculoskeletal ______Seizures______ Asthma_______Thyroid DX_______

HIV/Aids_______Smoking______Alcohol_______Illicit Drugs_________

Obesity_______, Eating Disorder_______ Mental Health_________

Depression and Anxiety________ Family loss_______

Financial loss_______ other____________________________

_______________________________________________________________

Do you take your regular prescribed medicines?  Yes_______  No______

Last Primary Care Physician visit________________

Signature____________________________________ Date_______________

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