This form outlines that you understand that a subcutaneous injection will be administered into your skin. This medication will be injected directly into the subcutaneous fat or muscle of your body. This is considered “Injection Therapy.” Please initial each point bellowing acknowledging that:
• I understand that injection therapy at (UBeU) is not intended to diagnose or treat a specific medical condition.
• I understand that the injection therapy will not prevent, treat, or cure and medical condition or disease. Furthermore, I understand that I am here seeking injection therapy voluntarily to assist with weight loss.
• I have informed (UBeU) of all the medications, supplements, and allergies that I have. I understand that serious adverse events could happen if I do not disclose all my drug/food/vitamin/and additional allergies and medications/supplements that I am currently taking.
• I understand that I have been informed of the procedure involving injection, the alternative treatment options, and the risks and benefits of the mutually agreed upon treatment.
• I understand that medication will be injected into my body fat.
• I understand that common risks involved with injection include, but are not limited to, irritation, pain, discomfort, bruising, and bleeding at the site of the injection.
• I understand that less common risks involved with injection therapy include, but are not limited to, infection at the site of the injection, injury to the tissue, medication interactions, and drops in blood sugar levels. This medication has not been studied in patients with a history of pancreatitis.
• I understand that rare side effect involved with injection include, but are not limited to, allergic reactions.
• I affirm that I am voluntarily seeking weight loss injection at (UBeU) and have not been coerced into doing so.
• I understand the risks and benefits of the injection and have had all my questions answered to my full satisfaction.
•I understand that unforeseeable complications can arise when an injection is injected into the body.
• I understand that I have the right refuse any treatments or treatment recommendations at any time.
This form outlines that you understand that a subcutaneous injection will be administered into your skin. This medication will be injected directly into the subcutaneous fat or muscle of your body. This is considered “Injection Therapy.” Please initial each point bellowing acknowledging that:
• I understand that injection therapy at (UBeU) is not intended to diagnose or treat a specific medical condition.
• I understand that the injection therapy will not prevent, treat, or cure and medical condition or disease. Furthermore, I understand that I am here seeking injection therapy voluntarily to assist with weight loss.
• I have informed (UBeU) of all the medications, supplements, and allergies that I have. I understand that serious adverse events could happen if I do not disclose all my drug/food/vitamin/and additional allergies and medications/supplements that I am currently taking.
• I understand that I have been informed of the procedure involving injection, the alternative treatment options, and the risks and benefits of the mutually agreed upon treatment.
• I understand that medication will be injected into my body fat.
• I understand that common risks involved with injection include, but are not limited to, irritation, pain, discomfort, bruising, and bleeding at the site of the injection.
• I understand that less common risks involved with injection therapy include, but are not limited to, infection at the site of the injection, injury to the tissue, medication interactions, and drops in blood sugar levels. This medication has not been studied in patients with a history of pancreatitis.
• I understand that rare side effect involved with injection include, but are not limited to, allergic reactions.
• I affirm that I am voluntarily seeking weight loss injection at (UBeU) and have not been coerced into doing so.
• I understand the risks and benefits of the injection and have had all my questions answered to my full satisfaction.
•I understand that unforeseeable complications can arise when an injection is injected into the body.
• I understand that I have the right refuse any treatments or treatment recommendations at any time.
