Weightloss RX Evaluation

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CURRENT WEIGHT & LOSS GOAL

BMI Categories:
Underweight = <18.5
Normal weight = 18.5–24.9
Overweight = 25–29.9
Obesity = BMI of 30 or greater

HEALTH INFORMATION

Semaglutide Screening: Do you have any of the following conditions *
Are you pregnant or breastfeeding? *
Please describe your alcohol consumption : *
Please describe the closest "work-out" level: *
Mark the medical conditions that apply to you or any immediate family
 MyselfFamily history
Scarlet Fever
Meningitis
Infectious Mononucleosis
Tuberculosis
Exposure to TB
Malaria
Bronchitis
Pneumonia
Pleurisy
Hepatitis (yellow jaundice)
Bladder infections
Rheumatic fever
Kidney disease
Hives
Hay fever/sinusitis
Asthma
Emphysema
Arthritis
Back trouble
High blood pressure
Heart disease
Anemia
Bleeding tendency
Nose bleeds
Ulcer
Cancer
Hemorrhoids
Blood transfusion
Diabetes
Do you have any of the following conditions? *
PATIENT CONSENT FOR PHYSICIAN TO USE OR DISCLOSE HEALTH CARE INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH CARE. *
I have recieved the HIPPA information *
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CONSENT FOR TEXT MESSAGING OF HEALTH INFORMATION 1. CONSENT TO RECEIVE TEXT MESSAGES By providing your mobile phone number and opting into text messaging services, you consent to receive health-related information, including but not limited to appointment reminders, treatment updates, and other relevant communications directly to your mobile phone via text message. 2. NATURE OF COMMUNICATIONS Text messages may contain sensitive health information, including details related to your medical care, appointment schedules, and other pertinent information regarding your treatment or health status. 3. CONFIDENTIALITY AND SECURITY While every effort will be made to ensure the confidentiality and security of your information, text messaging is not a fully secure method of communication. B. Sweet will use reasonable measures to protect the privacy of the information transmitted but cannot guarantee that text messages will be free from unauthorized access. 4. WITHDRAWAL OF CONSENT You may withdraw your consent to receive text messages at any time by notifying [Practitioner/Business Name] in writing or by contacting our office directly. Withdrawal of consent may result in the discontinuation of text messaging services. 5. ACKNOWLEDGEMENT AND ACCEPTANCE By providing your mobile phone number and agreeing to receive text messages, you acknowledge that you understand the nature of the communications you will receive, the potential risks involved, and the terms under which your health information may be sent to you via text message. 6. LIABILITY B. Sweet, its affiliates, employees, and agents shall not be liable for any unauthorized access to or interception of text messages, or for any damages arising from the use of text messaging services, including but not limited to, any loss or misinterpretation of health information. By continuing with the provision of your mobile phone number and agreeing to receive text messages, you confirm that you have read, understood, and accepted the terms and conditions outlined in this consent form. ACKNOWLEDGEMENT AND CONSENT REGARDING THE USE AND DISCLOSURE OF HEALTH INFORMATION 1. ACKNOWLEDGEMENT OF PRIVACY AND CONFIDENTIALITY I acknowledge that my health information is private and confidential. I understand that B. Sweet is committed to safeguarding my privacy and preserving the confidentiality of my personal health information. 2. CONSENT TO USE AND DISCLOSE HEALTH INFORMATION By signing this document, I consent to B. Sweet's use and disclosure of my personal health information for the purposes of providing health care services to me, handling billing and payment, and conducting other health care operations. I understand that my failure to sign this consent form may result in B. Sweet declining to provide treatment. 3. REQUEST FOR RESTRICTIONS Under the terms of this consent, I have the right to request B. Sweet to impose restrictions on how my personal health information is used or disclosed for treatment, payment, or health care operations. I acknowledge that B. Sweet is not obligated to agree to such restrictions. If B. Sweet does agree to my request, I understand that they will adhere to the agreed-upon limits. 4. RIGHT TO REVOKE CONSENT I understand that I have the right to revoke this consent in writing at any time. Should I choose to cancel this consent, I recognize that B. Sweet may have already used or disclosed my information, and revoking consent will not affect information that has already been used or disclosed. To cancel this consent, I must provide a written, signed, and dated letter to [Insert Provider Name Here] indicating my desire to revoke authorization for the use and disclosure of my personal health information for treatment, payment, and health care operations. 5. IMPACT OF CANCELLATION I understand that if I cancel this consent, B. Sweet is not obligated to provide further health care services to me. By signing this document, I confirm that I have read, understood, and agreed to the terms and conditions outlined herein. HIPPA I UNDERSTAND THAT MY HEALTH INFORMATION IS PRIVATE AND CONFIDENTIAL. I UNDERSTAND THAT B. Sweet WORKS VERY HARD TO PROTECT MY PRIVACY AND PRESERVE THE CONFIDENTIALITY OF MY PERSONAL HEALTH INFORMATION. I UNDERSTAND THAT SIGNING THIS DOCUMENT MEANS THAT B. SWEET MAY USE AND DISCLOSE MY PERSONAL HEALTH INFORMATION TO HELP PROVIDE HEALTH CARE TO ME, TO HANDLE BILLING AND PAYMENT, AND TO TAKE CARE OF OTHER HEALTH CARE OPERATIONS. FAILURE TO SIGN THIS CONSENT MAY RESULT IN THE PHYSICIAN DECLINING TO TREAT ME. UNDER THE TERMS OF THIS CONSENT, I CAN ASK B. SWEET TO RESTRICT HOW MY PERSONAL HEALTH INFORMATION IS USED OR DISCLOSED TO CARRY OUT TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS. I UNDERSTAND THAT B. SWEET / Beauty Bar Med-Spa DOES NOT HAVE TO AGREE TO MY REQUEST. IF HE DOES AGREE TO MY REQUEST, I UNDERSTAND THAT HE WOULD FOLLOW THE AGREED LIMITS. I UNDERSTAND THAT I HAVE THE RIGHT TO CANCEL THIS CONSENT IN WRITING AT ANY TIME. IF I DO CANCEL THE CONSENT, I UNDERSTAND THAT B. Sweet / Beauty bar Med-spa MAY HAVE ALREADY USED OR DISCLOSED INFORMATION ABOUT ME AND CANCELING THIS CONSENT WOULD NOT AFFECT THE INFORMATION ALREADY USED OR DISCLOSED. I MAY CANCEL THIS CONSENT AT ANY TIME BY DOING THE FOLLOWING: WRITING, SIGNING, AND DATING A LETTER TO B. SWEET MEDSPA THAT SAYS I WANT TO REVOKE MY CONSENT TO AUTHORIZE THE USE AND DISCLOSURE OF MY PERSONAL HEALTH INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH CARE OPTIONS. I UNDERSTAND IF I CANCEL THIS CONSENT, B. SWEET / Beauty Bar Med-SpaIS NOT OBLIGATED TO PROVIDE FURTHER HEALTH CARE SERVICES TO ME. * *

POSSIBLE SIDE AFFECTS & EXPECTATIONS

When starting semaglutide, individuals may experience several effects related to its intended therapeutic action as well as potential side effects. Here's what people can generally expect when they begin taking semaglutide:

  1. Blood sugar management: Semaglutide works to lower blood sugar levels by stimulating insulin secretion and reducing glucagon secretion, both of which help to control blood sugar levels. People may notice improvements in their blood sugar levels over time.

  2. Weight loss: Semaglutide is associated with weight loss in many individuals. This effect can be noticeable, and some people may experience a significant reduction in body weight over time.

  3. Decreased appetite: Semaglutide can lead to a decrease in appetite, which contributes to its weight-loss effect. People may find that they feel less hungry and have fewer cravings for food.

  4. Injection site reactions: Redness, swelling, or itching at the injection site is common, especially initially. These reactions typically diminish over time.

  5. Gastrointestinal effects: Nausea, vomiting, diarrhea, or abdominal discomfort are common side effects when starting semaglutide. These symptoms often improve as the body adjusts to the medication.

  6. Improved glycemic control: With consistent use, people typically experience better control over their blood sugar levels, leading to reduced risks of diabetes-related complications.

  7. Routine monitoring: Regular monitoring of blood sugar levels and potential side effects is important when starting semaglutide. Healthcare providers may adjust the dosage or provide additional guidance based on individual responses to the medication.

  8. Other potential effects: Some individuals may experience less common side effects such as hypoglycemia, increased heart rate, or, rarely, more serious issues like pancreatitis or kidney problems.

 

 

Semaglutide is a medication used primarily for the treatment of type 2 diabetes. Like any medication, it can have side effects. Common side effects of semaglutide may include:

  1. Nausea: This is one of the most commonly reported side effects. It usually occurs when treatment is initiated and may decrease over time.

  2. Vomiting: Some individuals may experience vomiting as a side effect of semaglutide.

  3. Diarrhea: Changes in bowel habits, including diarrhea, may occur with semaglutide use.

  4. Abdominal pain: Some people may experience abdominal discomfort or pain while taking semaglutide.

  5. Constipation: In some cases, semaglutide may cause constipation.

  6. Decreased appetite: Semaglutide may lead to a decrease in appetite, which can result in weight loss.

  7. Hypoglycemia: While less common compared to some other diabetes medications like insulin or sulfonylureas, semaglutide can cause low blood sugar levels (hypoglycemia), especially when used in combination with other blood sugar-lowering medications.

  8. Injection site reactions: Redness, itching, or swelling at the injection site may occur.

  9. Increased heart rate: Some individuals may experience an increased heart rate (tachycardia) while taking semaglutide.

  10. Pancreatitis: In rare cases, semaglutide may cause inflammation of the pancreas (pancreatitis), which can be serious.

  11. Kidney problems: There have been reports of kidney problems associated with semaglutide use, including kidney failure.

  12. Thyroid tumors: In animal studies, semaglutide has been associated with an increased risk of thyroid tumors, although it's not clear if this risk applies to humans.

Semaglutide for weightloss is not covered under insurence but we do take FSA/HSA

How would you like to receive your medication if prescribed? *
I certify that the information I have provided above is accurate to the best of my knowledge. I have been made aware of the side affects and potential issues with this weightloss medication and would like to proceed with treatment if prescribed *
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I acknowledge that beauty and medi spa treatments, including, but not limited to: skin care, massage, microablation, microdermabrasion, waxing, hair and scalp treatments, nail treatments, electrolysis, facial toning, permanent cosmetics, body treatments, ionization, laser treatments, tattoo removal, vein treatments, brown spot removal, BOTOX, Collagen, Dermal Fillers, PRP Injections, Sclerotherapy, Mesotherapy, Dermaplaning, tattoo removal, eyelash extensions, lash lifts and various other beauty procedures is not an exact science and no specific guarantees can or have been made concerning the outcome. I understand that some clients experience more change and improvement than others. In virtually all cases, multiple treatments are required in order to realize a difference. On behalf of myself, my heirs, my executors, and my administrators, I understand and agree to assume the following risks and hazards which may occur in connection with any particular treatment including but not limited to: unsatisfactory results, soreness, poor healing, discomfort, redness, blistering, skin damage, nerve damage, disability, death, scarring, infection, change in skin pigmentation, allergic reaction, eye damage, change or damage to my vision, muscle damage, and increased hair growth. I understand that even though precautions may be taken in my treatment, not all risks can be known in advance. Given the above, I understand that response to treatment varies on an individual basis and that specific results are not guaranteed. Therefore, in consideration for any treatment received, I agree to unconditionally defend, indemnify, hold harmless and release from any and all liability, costs of litigation and any other costs of every kind and nature, the company and the individual that provided my treatment, the insured, their insurance company, and any additional insureds, as well as any officers, directors, or employees of the above companies for any injury, property damage, condition or result, known or unknown, that may arise as a consequence of any treatment that I receive. In the event any provision of this agreement is found to be legally invalid or unenforceable for any reason, all remaining provisions will remain in full force and effect. In the event any provision of this document is found by a court of competent jurisdiction to exceed the limits permitted by any applicable law or to be invalid or unenforceable as written, such court (s) may exercise its discretion in reforming such provision(s) to the extent necessary to make it reasonable and enforceable. The undersigned waives, to the fullest extent permitted by law, any right they may have to a trial by jury in any legal proceeding directly or indirectly arising out of or relating to this agreement whether based in contract, tort, statute (including any federal or state statute, law, ordinance, or regulation), or any other legal theory. The client indicated below understands that any claims are processed through the insurance company’s South Dakota office and agrees that this contract will be governed and construed in accordance with the laws of the state of South Dakota and that all actions of any kind whatsoever will be filed, heard, governed, arbitrated, and restricted to the venue of the County of Meade County, South Dakota. The undersigned also agrees and stipulates that they will be responsible for any legal, or other costs of any kind, incurred by the insured or their insurance company in defense of this agreement should the undersigned challenge its enforceability. The client indicated below also agrees to forever hold harmless and release from any and all liability, claims, or demands of any kind or nature the insured, and their insurance company for the transmission of any disease, condition, injury or illness they may allege to have contracted or been exposed to as the result of any treatment, person, or visit at the insured's location or the location of treatment. I have fully disclosed on my client intake form any medications, previous complications, or current conditions that may affect my treatment. In store public area surveillance footage, text messages, or phone conversations by accessing, using, or continuing to use B. Sweet facilities and services, you acknowledge and agree that any video surveillance footage, text messages or phone conversations (collectively referred to as "Data") collected, recorded, or monitored by B. Sweet may be distributed, shared, or disclosed to third parties for purposes deemed necessary or appropriate by B. Sweet, including but not limited to, security, legal, regulatory, miscommunications, and investigative purposes. You further agree that B. Sweet shall have the right to retain, reproduce, and distribute the Data without further notice or consent, in accordance with applicable laws and regulations. In consideration for treatment received, I hereby grant permission to the individual or company that provided my treatment to use any photographic treatment records for the purposes of clinical and statistical studies, advertising, or additional compensation to me. By providing your contact information, including but not limited to your email address and/or telephone number, you hereby expressly consent to receive marketing communications, promotional offers, newsletters, and other information related to B. Sweet products and services via email, SMS, phone calls, or any other electronic or telephonic means, regardless of whether your number is on any state, federal, or corporate Do Not Call registry. You acknowledge that such consent is voluntary and not a condition of purchase. You further understand that you may withdraw your consent at any time by clicking the "unsubscribe" link provided in such communications or by contacting B. Sweet directly. Withdrawal of consent shall not affect the lawfulness of communications sent prior to such withdrawal. This consent shall remain in effect until revoked in writing or by stop instruction provided by SMS or Mailchimp *
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Our Nurse Practitoner will contact you with follow up questions in the next 48 hours.

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