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Weight Loss / GLP

GLP-1 (Glucagon-Like Peptide-1) therapy is an advanced medical treatment that helps regulate appetite, improve insulin sensitivity, and support sustainable weight loss. These medications—such as semaglutide and tirzepatide—work by mimicking a naturally occurring hormone that slows digestion, reduces hunger signals, and stabilizes blood sugar levels.

At Luz Lounge, our GLP-1 program is customized to your unique metabolic profile. Each client begins with a full clinical assessment, including a review of medical history, contraindications, and lifestyle factors. Our licensed providers monitor progress, adjust dosing as needed, and ensure safety through continuous follow-up and lab evaluation.

GLP-1 therapy is not a quick fix—it’s a medical partnership designed to help you reset your metabolism, restore energy, and achieve long-term results through balanced nutrition, physical activity, and guided medical supervision. Please complete the questionnaire below thoroughly so we can tailor your care safely and effectively. and paste the body of your waiver here.

Potential Risks & Complications

As with any medical treatment, GLP-1 receptor agonists carry potential side effects and risks. While many people tolerate therapy well, some may experience the following:

Common & Expected Effects

  • Mild nausea, bloating, or decreased appetite (especially during dose escalation)
  • Constipation, diarrhea, or mild abdominal discomfort
  • Fatigue or dizziness, particularly when eating too little
  • Mild headaches or “low blood sugar” sensations in sensitive individuals

Less Common but Reported Effects

  • Injection site redness, itching, or tenderness
  • Gallbladder issues or formation of gallstones related to rapid weight loss
  • Temporary hair shedding (telogen effluvium) during metabolic transition
  • Mood fluctuations or reduced alcohol tolerance

Serious but Rare Risks (require immediate medical attention)

  • Pancreatitis: sudden severe abdominal pain radiating to the back
  • Acute kidney injury or dehydration
  • Severe hypoglycemia if used with other diabetic medications
  • Allergic reaction: rash, swelling, or difficulty breathing
  • Possible thyroid C-cell tumors (seen in rodents; not confirmed in humans) — contraindicated for those with personal or family history of Medullary Thyroid Carcinoma (MTC) or Multiple Endocrine Neoplasia type 2 (MEN2)

If any unusual or severe symptoms occur, discontinue injections and contact your provider or seek urgent medical care.

By proceeding with GLP-1 therapy, you acknowledge that your provider has discussed the potential benefits, risks, and alternatives, and that results may vary based on adherence and individual response.



ARTICLE I: ARBITRATION Article 1.1: Agreement To Arbitrate: It is understood that any dispute as to medical malpractice by Client, including any party that would have standing to assert a claim on behalf of or in connection with services provided to Client, that is as to whether medical services rendered under this contract were unnecessary, unauthorized or lacking informed consent or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. For purposes of this agreement, “Dispute” means any claim or controversy of whatever kind or nature including (without limitation) any claim or controversy regarding the formation, validity, interpretation and/or enforceability of this agreement to arbitrate and any claim or controversy by the Client asserting loss of consortium, wrongful death, emotional distress or punitive damages. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Article 1.2: Procedure For Initiating Arbitration: Either party to this agreement may initiate Arbitration by submitting a Demand for Arbitration in writing to the other. The Demand shall contain a plain and simple statement of the nature of the Dispute and the remedy demanded. There shall be one Arbitrator who shall be a retired Judge of a court of record. The Arbitrator shall be selected by agreement of the parties on or before 30-calendar days of the date that the Demand for arbitration is deposited for delivery with a common carrier (as determined by a postmark or other equivalent writing imprinted by the common carrier). If the parties have not agreed to a selection of the Arbitrator, than either party may petition the appropriate Superior Court to appoint the Arbitrator and, consistent with CCP § 1281.6, the Superior Court shall appoint the Arbitrator, who shall have the qualifications stated in this paragraph. Article 1.3: Law Governing Arbitration; Arbitrator’s Award And Enforcement. Without reference to its choice of law rules, the Arbitrator shall apply the substantive state laws. The Arbitrator shall render his or her award in writing and the award shall separately state the Arbitrator’s findings of fact and conclusions of law. The Arbitrator’s award shall be binding on the parties to the arbitration and judgment on the award may be entered by a court of competent jurisdiction in state of treatment. Judicial proceedings to confirm, amend, or vacate the arbitration award shall also take place in state of treatment. To the extent permitted by law, venue for such proceedings shall be in the county (or the federal judicial district) where the services were rendered. Unless the Arbitrator shall determine otherwise, the Arbitration shall take place in the county where the services were rendered. The Arbitrator shall have the authority to hear any claim and award any remedy that could otherwise be heard or rendered by the Superior Court or a federal district court in my state. Discovery shall proceed in accordance with Code of Civil Procedure, and, in addition, any party, may, of right, bring a motion for summary judgment or adjudication in accordance with CCP § 437c. The parties to this agreement agree to arbitrate in one proceeding all claims arising out of the same or a related incident, transaction or occurrence. Article 1.4: Small Claims Court: Notwithstanding the foregoing any party to this agreement may initiate and prosecute in the small claims division of the Superior Court any claim at law demanding an amount equal to or less than the jurisdictional limit of the small claims division. Notwithstanding applicable law, no judgment in an action initiated in the small claims division may be entered for an amount in excess of the jurisdictional limit of the small claims division. Article 1.5: Severability: If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provisions. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY MUTUAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO JURY OR COURT TRIAL.


Today's Date: March 12, 2026


First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Discovery
What are your primary goals for starting a medical weight loss program?
Weight loss
Appetite control
Blood sugar regulation
Have you tried any weight-loss programs or medications before?
Yes
No
If yes, which ones and what was your experience?
Current weight:
Height:
Goal Weight:
How Often Do You Do Aerobic Exercise?*
How Often Do You Lift Weights*
Average hours of sleep per night.*
Recreational: Do you consume 3 or more of any of these per month?
Alcoholic Beverages
Smoking or Vaping
Drugs or Cannabis
None
Medical History - Please check all that apply:
Type 2 Diabetes
Prediabetes
PCOS
High blood pressure
High cholesterol
Thyroid disorder
Heart disease
Stroke
Kidney disease
Liver disease
Gallbladder disease or gallstones
Gastrointestinal issues (GERD, pancreatitis, gastroparesis, etc.)
History of cancer
Family history of thyroid cancer or MEN2
Depression or anxiety
Eating disorder history
Pregnancy
Currently breastfeeding
List all prescription, over-the-counter, or supplements you are currently taking (medication, dosage, reason):
Do you currently take any of the following?
Insulin or sulfonylureas (glipizide, glyburide, etc.)
Metformin
Corticosteroids
Antidepressants (SSRIs, MAOIs, etc.)
Antipsychotic or mood-stabilizing drugs
Blood pressure medication
Thyroid hormone replacement
Oral contraceptives or HRT
Other weight-loss medications (phentermine, topiramate, Contrave, etc.)
Contraindications & Caution Screening. Please check any conditions that apply.
Pancreatitis or severe abdominal pain
Personal or family history of Medullary Thyroid Carcinoma (MTC)
Multiple Endocrine Neoplasia type 2 (MEN2)
Severe GI or gastrointestinal disease (e.g., gastroparesis)
Severe renal impairment or dialysis
Severe hepatic impairment
Pregnancy or breastfeeding
Unexplained weight loss or appetite changes unrelated to diet
Known allergy to semaglutide, tirzepatide, or other GLP-1 receptor agonists
Headaches or Hypoglycemia or any other potential side effects?
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Signature*
Electronic Signature Consent*
 By signing below, I confirm that the information provided is accurate to the best of my knowledge. I understand that the provider will review this information to determine eligibility and appropriate dosing for GLP-1 or related therapies. I understand that results vary and ongoing medical supervision, proper diet, and lifestyle are required for safety and success.


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