Before my treatment, I have fully disclosed any medical conditions or diseases. If I fail to disclose any medical condition I have, I release the doctor and the center from any responsibility associated with this procedure.

I agree to immediately inform my healthcare provider of any issues that may arise during the treatment program. Additionally, I understand that failing to follow dosage recommendations and dietary restrictions could increase risks. If I do not follow these recommendations and restrictions, I agree to release the doctor and the center from any liability arising from this. While no adverse side effects or complications are expected, should an illness occur, I understand that I need to contact Dr. Echagarruga immediately. If I experience an emergency situation, I understand that I need to go to an emergency facility.

I understand that if there are any changes to my medical history, medications, or any other relevant changes for this procedure, I will inform the doctor at that time.

I give permission for photographs of the treated area(s) to be stored in my file and used for educational and/or promotional purposes. Complete confidentiality of my medical information will be maintained at all times.

I understand that I can be successful without the use of appetite suppressants or injections as long as I follow a calorie-restricted nutrition plan and increase my activity level. However, the use of such medications and injections can significantly help with my weight loss progress.
I understand that there is no guarantee that this program will work for me. I understand that I must follow the program as directed in order to achieve weight loss.

By giving my consent for treatment, I agree to pay in full for all visits and charges incurred at each one.
I have read and fully understand the above terms. All my questions have been addressed to my satisfaction. I agree to release the doctor and the center from any liability associated with this treatment.

Regarding Semaglutide:

I understand that my doctor is recommending a prescription for the medication Semaglutide to facilitate and promote weight loss.

Serious side effects of taking this medication may include: prolonged vomiting, inflammation of the pancreas (pancreatitis), vision changes, low blood sugar levels (hypoglycemia), kidney problems, and severe allergic reactions.

Common side effects may include nausea, vomiting, diarrhea, stomach pain, constipation, and possible ileus.

I agree to report any adverse reactions, side effects, or problems that may be related to Semaglutide.

I understand that I will be responsible for administering the prescribed medication and following the recommended dosages and administration methods provided by my doctor.

The medication provided to me is a compounded medication dispensed by a state-authorized pharmacy.

Semaglutide should be used with caution for individuals taking other medications to regulate blood sugar levels. Additionally, alcohol consumption should be limited while taking this medication.

By giving consent, I acknowledge that I am not currently suffering from any of the above conditions.

I certify that I have read this form and understand its contents. I have been given the opportunity to ask questions regarding my condition, the medication to be used, the risks and side effects involved, as well as alternative treatments. I have sufficient information to give this consent.