VITAMIN IV DRIPS

First and Last Name*

Email

Phone Number*

What is the date and time of your appointment?*

Your Address

Date of Birth

Please attach a copy of your Driver License

Do you have health insurance?
YesNo

Is Your insurance plan an HMO or PPO plan ?

Please attach a copy of your insurance card.

How did you hear about us?

Reason for visit?*
Weight LossIV DripOther

Race*

Name, Address and Phone of primary care physician?*

Do you have any of the following conditions?*
FibromyalgiaChronic Fatigue SyndromeLiver or Kidney problemsHeart ProblemsHigh Blood PressureThyroid IssuesHormone IssuesPre/Peri/Post MenopauseNone

Have you recently stopped or started smoking?
YesNoI have never smoked

Have you recently stopped, started, or changed birth control?*
YesNoI have never taken birth controlI am a male

Are you taking any blood thinners?*
YesNo

Are you pregnant or breast feeding?*
YesNoI am a male

Past surgical history:*

Prescription medications you are currently taking:*

Non-Prescription medications, vitamins or supplements you are currently taking:*

In the past, have you ever fainted, felt dizzy or had a reaction from getting an injection, IV Therapy or the from the sight of blood? (If yes, please explain)*

Do you drink alcohol?*

How Often

What is your weekly exercise and activity level?*
I am an Olympic AthleteExercise frequentlyRarelyNever

On a scale of 1-10, how motivated are you to lose weight? (10 being very motivated):*

I understand that any product, supplement, vitamin, or package I start will have an expiration date that is 4 months from the day it was started. After the 4-month period, medications are discarded and considered expired. (Some vitamins/supplements vary, please ask medical staff at consultation.)*
Yes

SIGNATURE. I HAVE READ THE Contraindications, Warnings, precautions below. I confirm that I do not have a history of any of these medical issues, and CONSENT TO TREATMENT BELOW.

Contraindications

Semaglutide ® is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2, and in patients with a hypersensitivity reaction to semaglutide or to any of the excipients in Semaglutide ®. Serious hypersensitivity reactions including anaphylaxis and angioedema have been reported with Semaglutide ®.

Warnings and Precautions

• Risk of Thyroid C-Cell Tumors: Patients should be referred to an endocrinologist for further evaluation if serum calcitonin is measured and found to be elevated or thyroid nodules are noted on physical examination or neck imaging.

• Pancreatitis: Acute and chronic pancreatitis have been reported in clinical studies. Observe patients carefully for signs and symptoms of pancreatitis (persistent severe abdominal pain, sometimes radiating to the back with or without vomiting). If pancreatitis is suspected, discontinue Semaglutide ® promptly, and if pancreatitis is confirmed, do not restart.

• Diabetic Retinopathy Complications: In a 2-year trial involving patients with type 2 diabetes and high cardiovascular risk, more events of diabetic retinopathy complications occurred in patients treated with Semaglutide ® (3.0%) compared with placebo (1.8%). The absolute risk increase for diabetic retinopathy complications was larger among patients with a history of diabetic retinopathy at baseline than among patients without a known history of diabetic retinopathy. Rapid improvement in glucose control has been associated with a temporary worsening of diabetic retinopathy. The effect of long-term glycemic control with semaglutide on diabetic retinopathy complications has not been studied. Patients with a history of diabetic retinopathy should be monitored for progression of diabetic retinopathy.

• Never Share an Semaglutide ® Pen Between Patients: Semaglutide ® pens must never be shared between patients, even if the needle is changed. Pen-sharing poses a risk for transmission of blood-borne pathogens.

• Hypoglycemia: Patients receiving Semaglutide ® in combination with an insulin secretagogue (eg, sulfonylurea) or insulin may have an increased risk of hypoglycemia, including severe hypoglycemia. Inform patients using these concomitant medications of the risk of hypoglycemia and educate them on the signs and symptoms of hypoglycemia.

• Acute Kidney Injury: There have been post marketing reports of acute kidney injury and worsening of chronic renal failure, which may sometimes require hemodialysis, in patients treated with GLP-1 receptor agonists. Some of these events have been reported in patients without a known underlying renal disease. A majority of the reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration. Monitor renal 6 function when initiating or escalating doses of Semaglutide ® in patients reporting severe adverse gastrointestinal reactions

• Hypersensitivity: Serious hypersensitivity reactions (e.g., anaphylaxis, angioedema) have been reported in patients treated with Semaglutide ®. If hypersensitivity reactions occur, discontinue use of Semaglutide ® ; treat promptly per standard of care, and monitor until signs and symptoms resolve. Use caution in a patient with a history of angioedema or anaphylaxis with another GLP-1 receptor agonist.

• Acute Gallbladder Disease: Acute events of gallbladder disease such as cholelithiasis or cholecystitis have been reported in GLP-1 receptor agonist trials and post marketing. In placebo-controlled trials, cholelithiasis was reported in 1.5% and 0.4% of patients treated with Semaglutide ® 0.5 mg and 1 mg, respectively, and not reported in placebo-treated patients. If cholelithiasis is suspected, gallbladder studies and appropriate clinical follow-up are indicated.

Adverse Reactions

The most common adverse reactions reported in ≥5% of patients treated with Semaglutide ® are nausea, vomiting, diarrhea, abdominal pain, and constipation.

Consents:

Consent to Treatment and other Acknowledgements:

By reading and signing this document, I, the undersigned patient (or authorized representative) consent to and authorize the performance of any treatments by Patients Medical Staff including injections, infusions, examinations, medications, anesthesia, medical services, and surgical or diagnostic procedures (including but not limited to the use of lab and radiographic studies) as ordered or approved by my attending physician(s), or any healthcare professional assigned to my care by my attending physician(s), and I acknowledge and consent to the following: During the course of my care and treatment, I understand that various types of examinations, tests, diagnostic or treatment procedures (“procedures”) may be necessary. These procedures may be performed by physician(s), nurses, technicians, physician assistants, or other healthcare professionals. While routinely performed without incident, there may be material risks associated with these procedures. If I have any questions concerning these procedures, I will ask my physician(s) to provide me with additional information. I also understand my physician may ask me to sign additional Informed 7 Consent documents relating to specific procedures. Anytime an injection is given, there is potential for pain, bruising, or swelling at the injection site. These reactions are mild and self-limited and usually resolve within 24-48 hours. Rare allergic reactions to the injection or infusion may occur. It is important that you inform the health care professional or proceed to the nearest emergency room if you experience severe side effects such as difficulty breathing, lips swelling, hives and chest pain. Physicians and healthcare professionals cannot guarantee any specific result(s) of any examination, treatment, procedure, or medical care. I release the Patients Medical staff, its physicians and healthcare professionals from any liability for any accident or injury that is not directly caused by the negligence of Patients Medical or its employees. I understand that the healthcare professionals involved in my care will rely on my documented medical history, as well as other information provided by me, my immediate family, or others having information about me, in determining whether to perform or recommend procedures. I agree that I have provided accurate and thorough information regarding my medical history and any conditions or events which may impact medical decision-making. In return for services to be provided by Patients Medical , I agree to pay for services rendered by Patients Medical to me or for my benefit. I agree to pay in full for such services at the time the services are received.

Consent to Membership in Weight Loss Program:

By reading and signing this document, I, the undersigned patient (or authorized representative) consent to membership in the $99 per month Patients Medical Weight Loss Program and authorize Patients Medical to charge my credit card $99 per month for 12 months for my one-year membership. I understand that I can pause this membership and/or cancel this membership at any time by payment of $99.00. I have received a copy of the details of the membership program and have read the program details and consent to the membership. By deciding to use a Program or otherwise taking part in it, you agree to: 1) pay Patients Medical monthly through the Payment Processor the Membership Fees for the Membership Option you have chosen in accordance with the applicable payment terms; and 2) give Patients Medical permission to charge your credit card monthly (your “Payment Method”) for all payments that are owed.

By signing this document, I certify that I have read and understand its contents and that the information provided by me is accurate and any questions I have been answered to my satisfaction. I believe I have adequate information and knowledge upon which to base an informed consent to the proposed procedure (Injection/Infusion). I am aware of the potential risks involved as outlined.

Date