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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

I understand the possible side effects from nausea the first few days to constipation that may occur from my regular bowel movements from every other day to possibly 1-2 times weekly. This is due to slower gastric emptying and lack of appetite and food intake. I am also aware of possibly side effects that may not be stated above but will understand to report it immediately to the clinic if anything does occur during any time of the treatment. I am aware that I will be educated on proper use/mechanism of action, of this weight loss injection and what to look for when self-injecting. I also know that it is important to still maintain an active lifestyle and incorporate exercise into my daily routine. This will help keep my skin and muscles tone. This will help to offset the weight loss that may contribute to bodily changes that may cause looser skin around the tummy, buttocks, arms, and face. Upon leaving the clinic with the injection it is my sole responsibility to not share with any individual the prescribed medication that has been given since it may cause harm and or side effects to someone else that has not been properly evaluate by a medical provider. I understand the prescription will come from a compounding pharmacy, which is not FDA approved. I have been told that the manufacturing facility itself is FDA monitored along with third party testing on the medication itself.

I understand that this is not a lifelong treatment but a temporary treatment of 6 months or less or until I have reached my goal weight. I do not hold Blessed Hands Clinic Inc. nor staff accountable for any unforeseen side effects that may occur with this treatment and am aware on how to reach out to the clinic and or any emergent facility if I were to have any emergent reactions at home with the administration of this treatment. I have read this form in its entirety. It has been explained to me. I have had the opportunity to ask questions and have all my questions answered. I fully understand the above information and have no further questions. By signing this form, I voluntarily give my consent for treatment and agree to the risks.

May 8, 2024

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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October 8, 2023 4:40 pm HST

Semaglutide / Cyanocobalamin Consent Form Uploaded by Lucky Robinson - [email protected] IP 72.234.27.111