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.