Semaglutide Intake Form

First Name *

Last Name *

Email *

Phone *

Date of Birth *

Client Questionnaire/Assessment Tool

Do you have Hypertension, Diabetes type 2, or Dyslipidemia? *

Yes

If yes, please explain below:

What is your Height?

What is your Weight?

What is your BMI?

Consent for Weight Loss Treatment Using Semaglutide

Please Initial After Each Statement Below

I do hereby authorize The DRIPBaR New Tampa / Michelle Gulizio APRN-C and staff, to assist me with weight reduction. I fully understand that this program shall consist of a reduction in caloric intake, regular exercise and behavioral lifestyle changes and my treatment may include the use of Semaglutide treatment and fat burning injections. I further understand that in order to continue to receive treatments, I must have regular follow up and show continued weight loss. Regarding the use of Semaglutides and other injectable vitamin supplementation, as with any prescription medication, I understand that there are potential risks involved. Side effects may include constipation, diarrhea, mild headaches, hypoglycemia, dry mouth, weakness, fatigue, medication allergy. Please initial below. *

I understand that these and other risks could be serious or in rare cases life threatening. Please initial below. *

I understand that if I develop side effects from the medication, I will discontinue taking the medication and notify the DRIPBaR New Tampa staff immediately and in the event the problem is severe, I will go to the nearest Emergency room for immediate care. I do not have a history of alcohol abuse, drug abuse, schizophrenia, manic-depressive illness, or eating disorder, since these conditions constitute a contraindication to the use of appetite suppressants. Please initial below. *

I agree not to take any other weight loss medications, other than those prescribed by Michelle Gulizio APRN-C and further agree to inform the staff of ANY changes in my medication or medical history. Please initial below. *

I understand that I can be successful without the use of Semaglutide injections as long as I am following a reduced calorie nutrition plan and increasing my activity level, however the use of such medications and injections may significantly help with my weight loss progress. Please initial below. *

I understand the risks associated with being overweight or obese include the possibility of high blood pressure, diabetes, heart disease, stroke, cancer, arthritis and pain of the joints, gallbladder disease and even sudden death. Please initial below. *

I understand that The DRIPBaR New Tampa / Michelle Gulizio APRN-C has found studies linking Semaglutide to be FDA approved for treatment of individuals with Type 2 Diabetes Mellitus as well as weight loss. Please initial below. *

L-Carnitine has also been studied to help with the treatment of is an amino acid that helps improve cellular energy. L-Carnitine may improve insulin sensitivity in diabetics by decreasing fat levels in muscle and may lower glucose levels in the blood by more promptly increasing its oxidation in cells. Please initial below. *

I agree to weekly weight assessment, vital signs and fulfill my obligations discussed with my provider. Please initial below. *

I understand that there is no guarantee that this program will work for me. I understand that I must follow the program as directed in order to achieve weight loss. By consenting to treatment, I agree to pay, in full, for all visits and charges incurred at each visit. I understand that these charges may or may not be covered by my insurance and DRIPBaR does not provide or fill out claim forms for insurance purposes. I also understand that no refunds are given out. Please initial below. *

INTRODUCTORY PRICE:

The DRIPBaR 8-week Starter Program is $600, with B12 Shots $760

(Dosing: 4 weeks at 1 unit / .25mg + 4 weeks at 2 units / .5mg)

The DRIPBaR offers packages beyond the 8-week starter program. Unit volume requires a quick approval from our medical provider.

- 4 weeks at 2 units / .5mg = $400

- 4 weeks at 4 units / 1.0mg = $600

- 4 weeks at 6 units / 1.5mg = $700

- 4 weeks at 8 units / 2.0 mg= $800

- 4 weeks at 10 units / 2/5,g = $1,000

Ask about our 16 week program for $2,000

MEMBERS SPECIAL: Receive complimentary blood draw for lab work and a B12 shot* for each week of your plan. *Members can substitute B12 for a B-complex

Required Blood Work

Comprehensive Metabolic Panel (CMP)
Lipid Panel
Blood work results must be within 90 days
The DRIPBaR New Tampa can assist with Labs. The Blood Draw fee is $80 and the Lab Fee is approximately $65 (Paid directly to the Lab).

By signing below, I certify that I have read and fully understand this consent form and understand the risks and benefits associated with my treatment for weight loss. Please sign full name below.

Signature: *

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