Semaglutide / Cyanocobalamin Consent Form
Consent for use of Semaglutide / Cyanocobalamin
Semaglutide/Cyanocobalamin: Compounded Weight-loss injection - Semaglutide binds andactivates the GLP-1 receptor. GLP-1 is an important, gut-derived, glucose homeostasis regulatorthat is released after the oral ingestion of carbohydrates or fats. GLP-1 suppresses glucagonsecretion, slows gastric emptying, reduces food intake, and promotes beta-cell proliferation.Cyanocobalamin (B12)- It’s responsible for many bodily functions and may benefit your healthin various ways, such as by preventing major birth defects, supporting bone health, improvingmood, and maintaining healthy skin and hair.
Directions: You will be shown how to self-administer injections in the clinic. Once you self-inject you will continue the same method at home. If unable to self-inject and not receivingany other treatment in clinic there will be a $25 charge for in clinic injection. Remember toalways clean the top of the vial with alcohol and then clean your injection location. Alwaysrotate sites weekly.
It is ok to stay at the same dose if you experience nausea/ increased constipation.Constipation of 2-3 bowel movements is normal. This is due to lack of food intake and decrease in gastricemptying. STARTING DOSE: 10 units MAX DOSE: 35 units
November 30, 2023
Clinical Staff: _________________________________Self-Administration/Demonstration Date: ________________________________________Approved for self-administration: YES or NO (circle one) If yes provide take home log for patient.
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Document Name: Semaglutide / Cyanocobalamin Consent Form
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