Loading...

The main benefits may include:

1. Wegovy (Semaglutide) is 94% similar to natural human GLP-1 and therefore acts as a physiological regulator of appetite and thereby reducing food intake by reducing feelings of

hunger and increasing feelings of fullness/satiety. The exact underlying mechanism of action is

2 Semaglutide is a newly licensed medication indicated for the treatment of type-2 diabetes. It is currently undergoing clinical trial to gain a license for the treatment of obesity. In the meantime, your medical practitioner may prescribe this medication for you 'off-label'

3. For long term success the treatment needs to be combined with lifestyle changes including nutritional, exercise and behavioural habits.

4. Weight loss can lead to secondary benefits by improving weight loss related health problems such as cardiovascular risk factors (including hypertension, blood glucose levels and waist circumference) and physical health-related Quality of Life.

I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent.

Since every human being is unique, we cannot guarantee any specific result from Semaglutide (Wehovy)  treatment. Medication and or medical conditions may have a negative impact on the outcomes as well as lifestyle factors. Treatment should be discontinued after 12 weeks if the patient has not lost at least 5% of their initial body weight.

Patients need to follow the instructions carefully as provided separately in the patient instruction sheet. Patients must agree to notify their practitioner of any contraindications or side effects of the treatment.

We will write to your GP to notify them of details of the program and any blood results (if completed

It is essential to engage with the 2 weekly telephone review and monthly face-to-face reviews with your doctor throughout the treatment program.

HEALTH CONCERNS: If you suffer from a medical or pathological condition, you need to consult with an appropriate healthcare provider such as your GP or Consultant. If you are under the care of another healthcare provider, it is important that you inform your other healthcare providers of your use of Ozempic. If you are using medications of any kind, you are required to alert us of.

Note:If you have any physicalor emotional reaction to Semaglutide treatment, discontinue use immediately, and contactyour PRACTITIONER to ascertain if the reaction is adverse or an indication of the natural course of the body's adjustment to the treatment.

Laboratory testing may be done to any patient identified at risk to determine areas of dysfunction, not to diagnose or treat. Potential blood tests:

  1. Full blood count
  2. Liver function test
  3. Kidney Function Tests
  4. Cholesterol levels, HbA1c, Glucose

Patient groups who may require blood test monitoring at additional cost:

  • Age 50 or above
  • High blood pressure
  • Pre-Diabetics
  • Any significant medical problem

I CONFIRM THAT I ACCEPT EXTRA BLOOD TESTS WITH FURTHER MONITORING AS ABOVE IF I  REQUIRED WITH ADDITIONAL COST AS SPECIFIED IN THE PATIENT PRICE LIST


  

COMMUNICATION: Every client is an individual, and it is not possible to determine in advance how your system will react to the treatment. It is sometimes necessary to adjust your program as we proceed. It is your responsibility to do your part by following healthy dietary guidelines, exercise your body and make necessary behavioural modifications.

1. Alternatives to Semaglutide therapy are surgical procedures, oral medical treatments (including Orlistat) and / or dietary and lifestyle changes alone. 2. Several weeks to months of treatment may be required depending on your individual response. 3. If a missed dose is more than 5 days late, the missed dose should not be taken, and the next dose should be taken at the normal time. 4. It is essential to combine eating, exercise and behavioural modifications with Semaglutide. 5. Semaglutide  should not be used in combination with another GLP-1 receptor agonist, insulin or insulin secretagogues (such as sulfonylureas) due to the risk of hypoglycaemia. 6. Upon initiation of Ozempic treatment in patients on warfarin or other coumarin derivatives more frequent monitoring of International Normalised Ratio (INR) is recommended. 7. Semaglutide causes a delay of gastric emptying and has the potential to impact the absorption of concomitantly administered oral medications. Monitor for potential consequences of delayed absorption of oral medications concomitantly administered with Semaglutide 

8. There are several special warnings and precautions for use of Semaglutide including warnings on pancreatitis, cholelithiasis and cholecystitis, thyroid disease, heart rate, dehydration and hypoglycaemia in people with type 2 diabetes.

Thyroid adverse events, such as goitre have been reported in particular in patients with pre-existing thyroid disease. Semaglutide should therefore be used with caution in patients with thyroid disease.

A higher rate of cholelithiasis and cholecystitis (gallstone and gallbladder disease) has been observed in patients treated with semaglutide. Cholelithiasis and cholecystitis may lead to hospitalisation and cholecystectomy (surgery to remove the gallbladder Patients should be aware of the characteristic symptoms of cholelithiasis and cholecystitis.

11. Signs and symptoms of dehydration, including renal impairment and acute renal failure, have been reported in patients treated with Semaglutide. Patients treated with semaglutide should be advised of the potential risk of dehydration in relation to gastrointestinal side effects and take precautions to avoid fluid depletion. Patients should also be aware of the symptoms of increased heart rate.

Acute pancreatitis has been observed with the use of Semaglutide. Patients and their carers should be told how to recognise signs and symptoms of acute pancreatitis and advised to seek immediate medical attention if symptoms develop. If pancreatitis is suspected, semaglutide should be discontinued; if acute pancreatitis is confirmed, semaglutide should not be restarted.

13. Semaglutide may cause dose-dependent and Itreatment-duration-dependent thyroid C-cell tumours at clinically relevant exposures in both genders of rats and mice. It is unknown whether Semaglutide  causes thyroid C-cell tumours, including medullary thyroid carcinoma (cancer, MTC), in humans, as the human relevance of semaglutide-induced rodent thyroid C-cell tumours has not been determined. Patients should be aware of symptoms of thyroid tumours (such as a mass in the neck, difficulty swallowing, difficulty breathing or shortness of breath, persistent hoarseness

Do not take Semaglutide if any of the below contraindications apply to you:

a. Aged under 18 or above 75

b. Severe renal/kidney impairment (with eGFR of 15 or below) or a history of renal disease

c.Severe hepatic/liver impairment

d. Personal or family history of medullary thyroid cancer (MTC)

e.Hypersensitivity to Semaglutide or to any of the excipients: disodium phosphate dihydrate, propylene glycol, phenol and water for injection. f. Concurrent treatment with any other products for weight management

g. Weight problems related to endocrinological or eating disorders h. Concurrent insulin or sulfonylurea

i.Patients on warfarin (more frequent INR monitoring required) j.Concurrent use of any medicinal products with may cause weight gain k. Pregnancy, breastfeeding or trying to/planning to become pregnant. Congestive heart failure

m. History of pancreatitis, gallbladder disease, inflammatory bowel disease, diabetic gastroparesis.

n. Patients with a personal or family history of MEN 2 (Multiple Endocrine Neoplasia syndrome

The below drugs interact with Semaglutide  and treatment of Semaglutide should not be used concurrently. Drug interactions:

  • Alogliptin
  • Biphasic insulin aspart
  • Biphasic insulin lispro
  • Biphasic isophane insulin
  • Canagliflozin
  • Dapagliflozin
  • Dulaglutide
  • Empagliflozin
  • Exenatide
  • Glibenclamide
  • Gliclazide
  • Glimepiride
  • Glipizide
  • Any insulin including aspart, degludec, detemir, glargine, glulisine, lispro, isophane, zinc suspension
  • Nateglinide
  • Pioglitazone
  • Repaglinide Saxagliptin, Sitagliptin, Vildagliptin
  • Tolbutamide

I am aware that other unforeseeable complications could occur. I do not expect the clinic COSMED LASER CENTER  to anticipate and or explain all risk and possible complications. I rely on them to exercise judgment during the course of treatment. I understand the risks and benefits of the treatment and have had the opportunity to have all of my questions answered


I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. At any stage during the treatment, I have the right to request that the procedure is terminated,however l accept that l will not be reimbursed once supply has commenced


 

1) I am clear about the risks of using this medication


 

2) I am clear about the expected weight loss outcomes of this weight loss program


3) I am clear about the diet , exercise and behavioral changes I need to make 


My signature on this form affirms that I have given my consent to the (Semaglutide) protocol as specified below:

 

I voluntarily request that Cosmed Laser Center MD Jodan Pathinathan treats my medical condition.


I have informed my provider of any known allergies, my medical conditions, medications, social/family history. 

I have the right to be informed of any alternative options, side effects, and the risks and benefits. 

I understand the mechanism of action of the medication.

I understand how it is to be administered. 

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.

It has been explained to me that this medication could be harmful if taken inappropriately or without advice from the provider. 

I understand this medication may cause adverse side effects . 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.


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


I take full liability and responsibility for any and all risks associated with this medication and treatment plan


I will not hold Cosmed Laser Center and  providers and staff liable any unfavorable outcome and adverse events





First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Past or current medical history
Past or current medical history
Medical conditions
Heart disease
Any Thyroid problem
Medullary Thyroid Cancer
Hypertension
Pancrease/digestion problem
Mental Health problem
Gall Bladder problem /Jaundice
Any allergies towards medications
Irritable bowel syndrome (IBS)
Stomach ulcer
Skin conditions
Eating disorder
Kidney problems including kidney chronic disease CKD
Liver problems ( including hepatitis , liver failure , fatty liver )
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!