Semaglutide Consent & Prescription Agreement

Semaglutide (GLP-1) Weight Loss Injection Management Consent

Olakino Wellness and Health, LLC.

Compounded Semaglutide Medical Consent & Prescription Agreement (DBA: Olakino Wellness and Health)

Last updated: February 14, 2024

Semaglutide (GLP-1) Weight Loss Injection Management Consent

This is an informed consent document to provide written information about the above- named treatment regarding risks, benefits, and alternatives. It is important that you understand the information provided to you prior to proceeding with this treatment.

By signing this form, I consent to the treatment provided by Olakino Wellness and Health, LLC using Semaglutide (GLP-1) injections for elective chronic weight management treatment.

Treatment benefits will vary by individual, but may include reduced appetite, feeling a sense of fullness for longer durations after eating (delayed gastric emptying), and increased fat-burning mechanisms which may result in weight loss. Additional therapeutic benefits related to weight management may include improved blood sugar levels and reduced risk of adverse cardiovascular events. I understand and agree that it is necessary for me to undergo a weight loss consultation with an Olakino Wellness and Health, LLC. provider. I have been informed and understand the following:

1.  Program Details:

Semaglutide weight management injections are used for weight loss along with a diet and exercise plan. These injections are delivered beneath the surface of the skin (subcutaneously) for chronic weight management in adults with obesity (BMI >30) or who are overweight (BMI>27) with at least one weight-related condition, including high blood pressure, diabetes type 2, and/or high cholesterol. Semaglutide mimics a glucagon-like peptide hormone called GLP- 1, which slows the movement of food from the stomach into the small intestine, helping to

reduce appetite and increase satiety after eating. Additional treatment benefits associated with these weight loss injections may include improved A1C and blood sugar levels by increasing insulin (a hormone that lowers blood sugar levels) and inhibiting glucagon (a hormone that raises blood sugar); improved blood pressure; reduced risk of major adverse cardiovascular events.

2.  Consultation:

I will participate in all required weight loss consultations with an Olakino Wellness and Health, LLC. provider during which my medical history, current health status, medication history, and weight loss goals with be routinely assessed. You will be counseled on nutrition and exercise recommendations to be used along with Semaglutide injections for chronic weight management, including reducing calories and increasing physical activity. You will be taught how to perform these injections at home just below the surface of the skin (subcutaneously) and will be prescribed a dosage that is adjusted for your individual needs, in accordance with your treatment plan. Common side effects include nausea, vomiting, diarrhea, indigestion, abdominal pain, constipation, fatigue, and dizziness.

Further, as a condition of your use of Olakino Wellness and Health, LLC, you agree that all information about you provided through the site is accurate, complete, and correct, and you will accurately maintain and update any of your Information that you have provided to Olakino Wellness and Health, LLC.

3.  Medication Use:

Semaglutide is a prescription medication used as an elective treatment for chronic weight management. Semaglutide mimics a glucagon-like peptide hormone called GLP-1, which slows the movement of food from the stomach into the small intestine, helping to reduce appetite and increase satiety after eating. Semaglutide may result in weight loss when combined with a healthy diet and physical exercise. Healthy weight loss is usually defined as 1-2 pounds per week. Extreme weight loss is not a medically desired effect. I understand that the use of these medications will be closely monitored by an Olakino Wellness and Health, LLC provider. Weight loss can vary depending on individual factors such as starting weight, metabolism, and overall health and consequently, Olakino Wellness and Health, LLC. does not provide refunds in the event of side effects or if the desired weight loss results are not achieved.

Dosing adjustments will be made by your treatment provider based on your body’s response and any side effects you’re experiencing. Treatment Regimen: Typical treatment regimen includes an initial series of weekly injections for 90 days, including follow-ups and lab work. Maintenance: Once you have achieved your weight loss goal, you may be weaned down to lower dosing of Semaglutide at specified intervals and/or given a maintenance protocol. Maintenance injections may be necessary to maintain desired results.

4.  Potential Treatment Benefits:

Semaglutide injection benefits may include weight reduction and/or weight management, improved glycemic control, and reduced risk of adverse cardiovascular events related to obesity. However, individual results may vary, and specific benefits cannot be guaranteed.

5.  Alternative Treatments:

Alternative forms of non-surgical and surgical treatment consist of: No treatment whatsoever, diet and lifestyle modifications, increased physical activity, other pharmaceutical weight management therapies, and bariatric surgery. Every procedure will involve a certain amount of risk. An individual’s

choice to undergo a procedure is based on the comparison of the risk to the potential benefit. Although most patients do not experience adverse complications, you should discuss your concerns and potential risks with your treatment provider to make an informed decision.

6.  Potential Risks/ Side Effects:

I acknowledge that there may be potential risks and side effects associated with the use of Semaglutide. The most common side effects reported include nausea, vomiting, diarrhea, abdominal pain, and constipation. The risk of serious side effects increases in patients with hypoglycemia, kidney problems, diabetic retinopathy, risk of pancreatitis, gastroparesis, and/or bowel obstruction.

This list is not exhaustive of all possible risks associated with Semaglutide weight management treatment, as there are both known and unknown side effects and risks associated with any medication or treatment.

I understand that it is essential to promptly report any side effects or concerns to Olakino Wellness and Health, LLC. provider for appropriate evaluation and management. If I have any concerns or experience any side effects, I should schedule an immediate appointment on the Practice Better portal, contact Olakino Wellness and Health LLC directly via phone (561) 923-0034, or we recommend seeking immediate emergency evaluation at your local Emergency Department.

7. Contraindications To Treatment:

Semaglutide injections are contraindicated in those who:

• Currently pregnant or breastfeeding
• History or current diagnosis of Medullary Thyroid Cancer (MTC) (including a family history of MTC)
• Current diagnosis of history of Multiple Endocrine Neoplasia Syndrome type 2 (MEN 2)
• Prior allergic reaction to Semaglutide or any of its active ingredients, which may include Vitamin B12 and/or Vitamin B6

Please tell your treatment provider if you have any other medical conditions, including the following, as Semaglutide injections may not be suitable for you:

• Plan to become pregnant
• Have, or have had, problems with your pancreas or kidneys
• Diagnosis Type 1 diabetes, type 2 diabetes, or a history of diabetic retinopathy
• Taking sulfonylureas or insulin
• Currently be treated for or history of depression, mental health issues, and/or suicidal ideations
  
  

Please read the information linked below. It contains important warnings from the FDA about medications you may be prescribed. If you have any questions, please speak to your provider.

Semaglutide (Active Pharmaceutical Ingredient in (Wegovy®) https://uspl.lilly.com/mounjaro/mounjaro.html#pi

8. Storage, Supply, and Administration of Semaglutide:

During your initial consultation, an Olakino Wellness and Health, LLC., provider will guide and demonstrate the proper technique for self-administering the subcutaneous injection. Refer to the accompanying instructions and complete administration instructions. The patient is responsible for adhering to the dosage schedule discussed with your provider and included with the prescription. Administration is once weekly, on the same day each week, at any time of day, with or without meals. Administer subcutaneously in the abdomen, thigh, or upper arm. The time of day and injection site can be changed without dose adjustment. This medication is shipped directly from the pharmacy as a single vial with individual weekly syringes to self-withdraw and inject. Keep refrigerated to maintain the potency and integrity of the medication.

Compliance: I agree to follow the prescribed treatment plan, including medication administration, participating in all required consultations, dietary recommendations, exercise guidelines, and any additional instructions provided by Olakino Wellness and Health, LLC. provider. I understand that adherence to the program is crucial for achieving optimal results.

9. Responsibility:

I take full responsibility for my participation in the Semaglutide Weight Loss Program and any potential outcomes that may arise. I understand that weight loss results can vary, and that success depends on my commitment, lifestyle modifications, and adherence to the recommended program. I assume full liability for any adverse effects that may result from the non-negligent administration of the proposed treatment. I waive any claim in law or equity for a redress of any grievance that I may have concerning or resulting from the treatment, except as that claim pertains to the negligent administration of this procedure.

In some situations, it may not be possible to achieve desired weight loss results. It is also possible that Semaglutide injections may fail to produce any reduction in weight. Should complications occur, additional or other treatments may be necessary. Semaglutide injections are not a permanent solution for weight management and must be maintained with lifestyle and diet modifications; you may also require maintenance injections to maintain desired weight. As a weight management treatment, it is recommended to allow at least 90 days of treatment to achieve results. Duration of results is unknown and not guaranteed.

10. Patient Acknowledgment:

By signing this patient waiver, you are acknowledging that the outcomes of the treatment cannot be guaranteed. Consequently, Olakino Wellness and Health, LLC. does not provide refunds in the event of side effects or if the desired weight loss results are not achieved. If you experience side effects, please contact our office, and we will guide appropriate measures, which may include prescribing a prescription anti-nausea medication.

I acknowledge that I understand the regular charge applies to all treatments. I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I acknowledge that most insurances do not cover the cost of weight loss injection treatment, and therefore, I am required to pay for services and medication out of pocket. In the event that I am not satisfied with my results, I agree not to seek a refund for Semaglutide treatment services rendered, as I am fully aware that there is no implied or explicit guarantee of results, as stated in the acknowledgement above.

I further agree in the event of non-payment and/or reversal of payment via a credit card dispute that I initiate, I will bear the cost of collection fees, and/or court fees, and/or any reasonable legal fees resulting from such instance.

INDEMNIFICATION

You agree to defend, indemnify, and hold harmless Olakino Wellness and Health, LLC.., its clients, its suppliers, any Third-Parties offering products or services through the Service, including its Providers, Labs and Pharmacies, and their respective affiliates, employees, officers, directors, agents, servants, shareholders, and representatives of each from and against any and all suits, actions, claims, proceedings, damages, settlements, judgments, injuries, liabilities, obligations, losses, risks, costs, and expenses (including, without limitation, attorneys’ fees and litigation expenses) relating to or arising from your use of the Service, prescribed medications, your fraud, violation of law, or willful misconduct, any breach by you of this Agreement or your violation of any rights of any other person or entity. We reserve the right to control the defense of any claim by a third party for which we are entitled to indemnification, and you agree to provide us with such cooperation as is reasonably requested by us.

By signing below, I acknowledge that I have read and understood the information provided in this waiver. I am aware of the potential risks and benefits associated with the Semaglutide Weight Loss Program and willingly consent to participate.