Semaglutide/Tirzepatide have been proven to aid in weight loss, I understand that there is no warrant or guarantee of my results from using Semaglutide/Tirzepatide weekly injections. I understand that risks may be involved, as there are with all medications. Failure to comply with dosage directions and dietary could possibly alter my weight loss results. I understand and agree that I am, and will be, under the care of my PCP for all other medical conditions. We do not accept or bill insurance for this program. I understand that my medication will be ordered on a per patient per monthly basis and that I am to pay in advance for the full month of injections. At any point I can choose to discontinue the 1-month program only. 

I acknowledge that all statements provided on the Medical History Forms are true and accurate to the best of my knowledge and that my treatments will be based on the information provided herein and if I willingly withhold information, I accept full liability for any consequence that may arise therefrom. SEMAGLUTIDE/TIRZEPATIDE CONTRAINDICATIONS: I UNDERSTAND THAT IF I HAVE ANY OF THE FOLLOWING I SHOULD NOT TAKE SEMAGLUTIDEIRZEPATIDE INJECTIONS: pregnant, trying to become pregnant, breast feeding, diabetic retinopathy (a type of damage to the eye from diabetes), low blood sugar, decreased kidney function, pancreatitis, history of pancreatitis medullary thyroid cancer, multiple endocrine neoplasia type 2, family history of medullary thyroid carcinoma and/or kidney disease with likely reduction in kidney function. I have read and understand the above statements and conditions and have been informed of potential side effects and risks that may be associated with the use of Semaglutide/Tirzepatide. I fully understand what I am signing and hereby request and consent to use of Semaglutide/Tirzepatide.