Semaglutide / Cyanocobalamin Consent Form

Consent for use of Semaglutide / Cyanocobalamin

Semaglutide/Cyanocobalamin: Compounded Weight-loss injection - Semaglutide binds and
activates the GLP-1 receptor. GLP-1 is an important, gut-derived, glucose homeostasis regulator
that is released after the oral ingestion of carbohydrates or fats. GLP-1 suppresses glucagon
secretion, slows gastric emptying, reduces food intake, and promotes beta-cell proliferation.
Cyanocobalamin (B12)- It’s responsible for many bodily functions and may benefit your health
in various ways, such as by preventing major birth defects, supporting bone health, improving
mood, 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 receiving
any other treatment in clinic there will be a $25 charge for in clinic injection. Remember to
always clean the top of the vial with alcohol and then clean your injection location. Always
rotate 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 gastric
emptying. STARTING DOSE: 10 units MAX DOSE: 35 units





July 18, 2024





Clinical Staff: _________________________________
Self-Administration/Demonstration Date: ________________________________________
Approved for self-administration: YES or NO (circle one) If yes provide take home log for patient.

Leave this empty:

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Signature Certificate
Document name: Semaglutide / Cyanocobalamin Consent Form
lock iconUnique Document ID: 71d4b6c99dbabfabf63a81678476c1f5a4343540
Timestamp Audit
October 8, 2023 4:40 pm HSTSemaglutide / Cyanocobalamin Consent Form Uploaded by Lucky Robinson - [email protected] IP