SEMAGLUTIDE CONSENT | Aesthetics Forms Portal

Semaglutide / Tirzepatide / MetaSlim 360 Consent Form

Procedure Information:

You are being offered treatment with Semaglutide and/or Tirzepatide for weight management. These medications are GLP-1 receptor agonists that help to regulate appetite and blood sugar levels.

Potential Benefits:

Weight loss
Improved blood sugar control
Reduced appetite

Possible Side Effects:

Nausea
Diarrhea
Vomiting
Abdominal pain
Risk of thyroid tumors
Pancreatitis

Do you suffer from any health disorder with: *

Heart problems High blood pressure DIABETES Respiratory diseases Psychiatric disorders Thyroid Pancreatic - None of the above

Write down the medications you use.

Consent:

I have been informed about the potential benefits and side effects of Semaglutide and Tirzepatide.

I understand that while these medications can aid in weight management, they are not a substitute for a healthy diet and regular exercise.

I acknowledge that I have discussed my medical history with the healthcare provider and have had the opportunity to ask questions regarding the treatment.

I consent to the administration of Semaglutide and/or Tirzepatide as part of my treatment plan.

DATE OF BIRTH *

FULL NAME *

DATE

SHIPPING ADDRES (if necessary):

HEIGHT

WEIGHT

SINGN

Tap or click on the signature above to sign