WEIGHT LOSS INJECTIONS INTAKE FORM
ALL INFORMATION IS CONFIDENTIAL
How did you hear about us?
What are your main weight issues and goal?
Are you currently on any weight loss programs or special diet? Yes No
If Yes, please explain:
Do you smoke? Yes No
If Yes, how many per day:
Do you consume alcohol? Yes No
If Yes, what is your weekly consumption?
Do you take any medication, birth control, vitamins, mineral or herbal supplements?
Yes No
If Yes, please list all medications:
Do you exercise regularly? Yes No
If Yes, please specify:
Do you have any type of injury or have you had any type of operation in the last 12 months?
Yes No
If Yes, please specify:
Do you have any Allergies Yes No
If Yes, please list all allergies and/or reactions to drugs, food, latex, etc.:
Please list all Surgeries and other Hospitalizations:
Do you currently have or have you had any of the following Health Conditions (Check all that apply):
Are you currently under the care of a Physician? Yes No
If Yes, please list name of Dr. and Contact Info:
Have you ever had weight loss surgery? Yes No
If Yes, date of procedure:
If yes to above, Highest Pre-Surgery Weight:
Lowest Post Surgery Weight:
What do you feel are the main contributors to having excess weight? (Check all that apply):
What foods do you crave most often and how often do you eat these foods?
What methods have you used in the past for weight loss?
Exercise Diet Modifications Prescription Medications Weight Loss Pills
Therapy Injections
Please list details of items marked above:
Do you experience any potential weight loss obstacles below?
Skipping Meals Binge Eating Stress Eating
Psychological Factors Unsupportive Partner None
Please specify if you marked any of the above items:
How long has your weight been an issue?
What is your ideal weight?
What is your heaviest weight?
Are you currently at your heaviest weight? Yes No
If Yes, for how long?
I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform the practitioner or other health professional of my current medical health conditions and to update this history. A current medical history is essential for the practitioner to execute appropriate treatment procedures, I have read and understand the above medical history questionnaire. I acknowledge that all answers have been recorded truthfully and will not hold any staff member responsible for any errors or omissions that I have made in the completion of this form.
Client Name:
Client Signature:
Date:
Weight Management Prescription Drug Management Consent for Semaglutide and Tirzepatide
This document is intended to serve as a confirmation of informed consent for compounded semaglutide and Tirzepatide, which is a prescription weight management medication.
Semaglutide is a glucagon-like peptide 1 receptor receptor substance that reduces appetite so the user minimizes their food intake. Branded names for this are known as Ozempic and Wegovy.
Tirzepatide is a dual glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 receptor substance that regulates blood sugar levels and stimulates weight loss. Tirzepatide works by controlling blood sugar and slowing down digestion; this causes the user to feel full faster. Branded names for this are known as Mounjaro.
A. Patient Informed Consent
1. I voluntarily request that Dr Fara Movargharnia treats my medical condition.
2. I have informed my provider of any known allergies, my medical conditions, medications, social/family history.
3. I have the right to be informed of any alternative options, side effects, and the risks and benefits.
4. I understand the mechanism of action of the medication.
5. I understand how it is to be administered.
6. I understand the prescription will come from a compounding pharmacy, which is not FDA approved. I have been told that the manufacturing facility itself is FDA monitored along with third party testing on the medication itself.
7. Prices may vary and change depending on promotions and dosage amounts.
8. Dr. Fara Movagharnia may change the pharmacy based on several factors (availability, shipping time, cost). Dr. Fara will tell you as this happens.
9. It has been explained to me that this medication could be harmful if taken inappropriately or without advice from the provider.
10. I understand this medication may cause adverse side effects (see below). I understand this list is not complete and it describes the most common side effects, and that death is also a possibility of taking this medication. I understand symptoms may be worse after there has been a change in my medication dose or when first starting the medication.
Common side effects include, but are not limited to:
● Gastrointestinal: Nausea/vomiting, abdominal pain, upset stomach, heartburn, burping, gas, mild to excessive bloating, loss of appetite, stomach flu symptoms, diarrhea/constipation, dyspepsia, abdominal distension, eructation, flatulence, gastroenteritis, GERD, gastritis, lipase increase, amylase increase, acid reflux
● Neurological: Headache, dizziness, tiredness, anxiety, chills, cold sweats, depression, recurrent fever
● Cardiac: Heart rate increase, Hypotension, shortness of breath, irregular heart beat, difficulty breathing
● Endocrine: Fatigue, hypoglycemia (diabetic patients), alopecia
● Ophthalmic: Retinal disorder (diabetic patients) , yellowing of eyes or skin, vision changes
● Skin: redness or pain at injection site, skin itching, rash, redness
● Low blood sugar
● Hair loss
Serious Reactions include, but are not limited to:
● Thyroid C-cell tumor (animal studies)
● Thyroid Cancer
● Medullary thyroid cancer
● Hypersensitivity reaction
● Anaphylaxis
● Angioedema
● Acute kidney injury
● Kidney failure
● Chronic renal failure exacerbation
● Gallbladder problems, gallbladder disease
● Pancreatitis
● Cholelithiasis
● Cholecystitis
● Syncope
● Allergic reactions
● Swelling of the face, throat or tongue
● Difficulty breathing or swallowing
B. I understand that I have the following responsibilities:
1. I agree to obtain prescriptions for compounded semaglutide / Tirzepatide only from Dr. Fara Movagharnia with Nyah Med Spa.
a. If I am looking to transition to a non-compounding pharmacy or seek insurance coverage, I will tell Dr Fara in advance.
2. Medical history: I will tell Dr. Fara my complete medical history, including: allergies, medications, medical/surgical/social/family history.
a. Dr. Fara may ask to review, with your permission, your medical history (medications, recent lab results, pertinent imaging results).
b. I understand that if I become pregnant or start trying for pregnancy, I must stop this medication.
c. I will be honest to the best of my ability the history she needs to know.
d. I will tell my provider any updated health information (medication, allergies, personal medical issues/surgeries/social history, or family history changes).
e. My provider can discuss my treatment plan with any co-treating pharmacist and/or healthcare provider
f. I will always tell other providers about all medications I am taking.
g. Dr. Fara may ask for me to seek additional labs while on treatment to ensure it’s safety.
3. Directions for use: I will take my medications only as prescribed according to the directions, led by Dr. Fara Movagharnia..
a. If I feel my medications are not effective, or are causing undesirable side effects, I will contact my provider for instructions.
b. I will not adjust my medications without prior instruction to do so.
c. I understand that the medication must be either kept frozen or refrigerated.
d. I understand this medication must be self-injected in the subcutaneous tissue once weekly. I will not inject any less than 7 days unless directed by Dr. Fara (example: travel).
e. I will not share needles and dispose of needles safely.
f. If I’m having troubles with the administration of the medication, I will seek help from Dr. Fara Movagharnia.
g. The medication expires after 12 weeks. I will refer to the Beyond Usage Date (BUD).
4. Refills:
a. All refills will require an appointment.
b. I understand, I may need to schedule refill appointments ahead of time to avoid delays in refills.
c. Refills will get ordered Monday.
d. I will not ask for early refills.
e. I understand that I may be asked to bring the medication with me to my appointments to check the quantity left or asses how I am injecting.
5. Safety:
a. I understand it is important to keep my medication away from children (<18 years old)
b. I am the only one who will use my medication. I will not give or sell my medication to anyone else.
6. If Dr. Fara deems it appropriate to start weaning my medication or transition to maintenance dosing, I will comply.
C. Discontinuation of medication: I understand that Dr. Fara may stop prescribing my medications if:
a. I am having unfavorable side effects or it’s not working to treat my medical condition
b. I have been untruthful in my medical or family history
c. I do not follow through with the recommended plan of care set by Dr. Fara Movagharnia.
d. I do not follow any parts of “Part B: responsibilities” in this agreement.
While using Semaglutide or Tirzepatide, it is highly recommended that you:
• Eat a fibrous diet. Focus on fruits and vegetables that are high in fiber.
• Eat small high protein meals as digestion is slowed down while on this medication.
• Avoid foods high in fat as they take longer to digest.
• Limit alcohol intake as this medication can lower blood sugar.
• Drink at least 32 oz of water per day to avoid constipation.
Do not take this medication if:
• You have a personal or family history of medullary thyroid carcinoma (Thyroid Cancer)
• Multiple Endocrine Neoplasia Syndrome type 2
• You are pregnant or plan to become pregnant while taking this medication.
• You are diabetic and/or taking any medications related to lowering your blood sugar levels without speaking with your endocrinologist.
• Specifically, if you are prescribed insulin – because the combination may increase your risk of hypoglycemia (low blood sugar).
• You have a history of Pancreatitis.
• You are allergic to Semaglutide,Tirzepatide, BPC-157, or any other GLP-1 Agonist such as Ozempic, Wegovy, Adiyxin, Byetta, Bydurteon, Rybelsus, Trulicity, Victoza.
• If you have other allergies. This product many contain inactive ingredients, which can cause allergic reactions, which can cause allergic reactions or other problems. Talk to your pharmacist for more details. Before using this medication, tell your doctor your medical history.
Possible drug interactions: Anti-diabetic agents, specifically: Insulin and Sulfonylureas (i.e., glyburide, glipizide, glimepiride, tolbutamide) due to the increased risk of hypoglycemia (low blood sugar). Do not take with other agonist medicines such as: Ozempic, Wegovy, Adiyxin, Byetta, Bydurteon, Rybelsus, Trulicity, Victoza (THIS MAY NOT BE AN ALL-INCLUSIVE LIST). Other medications used in diabetes, please tell your provider about any medications that may lower your blood sugar.
Possible side effects: Nausea, diarrhea, vomiting,
Semaglutide / Tirzepatide protocol:
● Every 30 days you must request a refill and self-report: current weight, blood pressure, concerns regarding treatment, change in other prescribed medications, change in medical history, change in desired weight loss outcome.
● The most efficient method to request a refill is through calling the office to book an appointment.
● It can take 7-10 business days to receive some forms of semaglutide. Please be mindful of self-reporting in a timely manner to not delay your administration.
● We do offer in office visits and assistance. Please notify our office immediately so we can get you in touch with Dr. Fara for any concerns or issues.
● In the event of an emergency, call 911 immediately.
IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THIS TREATMENT, OR ANY QUESTIONS CONCERNING THIS PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK NOW BEFORE SIGNING THIS CONSENT FORM.
By signing, I certify that I have read and understand the contents of this form. I am aware of the possible side effects and drug interactions and give my consent for treatment. I have informed the medical staff of any known allergies to drugs or other substances, and any past adverse reactions I’ve experienced. I have informed the medical staff of all medications and supplements I’m currently taking. I understand there are other ways and programs that can assist me in my desire to decrease my body weight and acknowledge that no guarantees have been made to me concerning my results.
RELEASE FROM MEDICAL LIABILITY AND MALPRACTICE CLAIMS:
I agree to release Dr. Fara Movagharnia and Nyah Med Spa and all their associates from all medical liability and malpractice claims related to any and all care.
This consent covers the initial and all future prescriptions for this medication.
I understand that this is a prescription therapy and is not eligible for a refund or reimbursement.
I have read and agree to the above. My questions have been answered and I understand the treatment and goals. I understand and accept the potential risks associated with Semaglutide / Tirzapatide as stated above and consent to treatment.
I agree to release Dr. Fara Movagharnia and Nyah Med Spa and all their associates from all medical liability and malpractice claims related to any and all care.
Please check below:
I agree
I have read through all the above information and if I have questions I will ask the doctor.
Please check below:
I agree
I certify that I have been informed of the risks and benefits of off-label treatment.
Please check below:
I agree
I will review the side effects of all medications I am prescribed and immediately inform the doctor of any side effects.
Please check below:
I agree
Medical Disclaimer
Patient agrees to virtual e-visit service terms, privacy policy, for receiving a virtual visit from Dr. Fara Movagharnia at Nyah Med Spa. Requests for e-visits must be confirmed and scheduled by our office prior to the e-visit. Prior to the visit please fill out all medical forms for Semaglutide. After reviewing your information, or during the e-visit it may be determined that your problem is too complex for an e-visit session. In that case our office will schedule you for a traditional office visit with Dr. Fara. Our physician appropriately documents the virtual e-visit, including all pertinent communication related to the encounter, in the patient’s medical/health record. The physician has a defined period of time within which responses to a virtual e-visit request are completed. During the virtual e-visit, the physician may make recommendations, provide medical advice and/or prescribe, refill or recommend medications. The physician may suggest the patient receive additional care, examination, testing and/or treatment at a medical facility in-person. If necessary, the physician may also suggest that the patient receive care in an emergency room. Communication during an e-visit may be exchanged via teleconference, landline phone, cellular phone and online chat per state of Georgia. By requesting an e-visit you acknowledge that personal health information will be communicated. A virtual e-visit may include the total interchange of online inquiries and other communications associated with this single patient encounter, subject to determination of the physician. As with any medical service, decision, or treatment, there are risks; and, an e-visit is no different. Because this visit is electronic and not in person, you acknowledge that the risk may be greater than a traditional office visit, and by requesting the visit you agree to accept the outcome-even if it is undesirable. In addition, you agree to abide by our office's routine policies including any policy related to litigation. I acknowledge I am receiving a telemedicine consult with the physician and the outcome will be based solely on the physician's medical discretion.
Signature
I acknowledge and agree that I have read the Medical Disclaimer above and I am authorizing Dr. Fara Movagharnia and any staff member of Nyah Med Spa , if present to proceed with our telemedicine visit.
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I have read this form in its entirety. It has been explained to me. I have had the opportunity to ask questions and have all my questions answered. I fully understand the above information and have no further questions. By signing this form, I voluntarily give my consent for treatment and agree to the risks.
Please sign:
Date