, (patient/guardian) do hereby authorize Aesthete Beauty Co, to assist me with weight reduction. I fully understand that this program shall consist of a reduction in caloric intake, regular exercise, behavioral and lifestyle changes and my treatment may include the use of prescription medications (Semaglutide/ Tirzepatide) and fat burning injections. I further understand that in order to continue to receive medications, I must have regular follow up and show continued healthy weight loss. Regarding the use of medications, as with any prescription medication, I understand that there are potential risks involved.
I confirm that I do not have a personal or family history of medullary thyroid cancer or multiple endocrine neoplasia.
I confirm that I do not have a history of gallbladder disease or pancreatitis.
I confirm that I am not pregnant or breastfeeding and will inform my provider immediately if I become pregnant.
Side effects may of Semaglutide and Tirzepatide include acid reflux, hypoglycemia, bloating, increased heartrate, loss of appetite, gallbladder disease, kidney disease, constipation, diarrhea, upset stomach, headaches, weakness, fatigue, medication allergy. I understand that these and other risks could be serious or in rare cases life threatening.
I understand that if I develop side effects from the medication, I will discontinue taking the medication and notify Aesthete Beauty Co staff immediately. In the event the problem is severe, I will go to the nearest Emergency room for immediate care.
I do not have a history of alcohol abuse, drug abuse, schizophrenia, manic-depressive illness, or eating disorder, since these conditions constitute a contraindication to the use of weight loss medications.
I agree not to take any other weight loss medications, other than those prescribed by Aesthete Beauty Co and further agree to inform the staff of ANY changes in my medication or medical history.
I understand that I can be successful without the use of medications as long as I am following a reduced calorie nutrition plan and increasing my activity level, however the use of such medications and injections may significantly help with my weight loss progress. I understand the risks associated with being overweight or obese include the possibility of high blood pressure, diabetes, heart disease, stroke, cancer, arthritis and pain of the joints, gallbladder disease and even sudden death.
I understand that Bariatric Physicians have found appetite suppressants helpful for periods longer than those suggested in the medication labeling and at times in larger doses. Aesthete Beauty Co is not required to use the medications as the labeling suggests but does use it as a source of information along with experience, the experiences of his colleagues, as well as recent studies and recommendations of investigators and professional societies.
I understand that there is no guarantee that this program will work for me. I understand that I must follow the program as directed in order to achieve weight loss. By consenting to treatment, I agree to pay, in full, for all visits and charges incurred at each visit. I understand that these charges may or may not be covered by my insurance and Aesthete Beauty Co does not provide or fill out claim forms for insurance purposes. I also understand that no refunds are given out.
By signing below, I certify that I have read and fully understand this consent form and understand the risks and benefits associated with my treatment for weight loss. Patient
