Consent, Autorization and Notice of Privacy Practices

I understand that my private healthcare information is protected under HIPPAA Privacy Regulations.

I fully understand that my signature is consent and authorization to receive the Semaglutide administration via subcutaneously by the authorized health care professional.

I understand the science behind Semaglutide and am aware of the possible and common side effects, including nausea, vomiting, diarrhea, abdominal pain, constipation, heartburn, headache, fatigue, dyspepsia, dizziness, abdominal distention, eructation, retinal disorder (in clients with diabetes mellitus), hypoglycemia (in clients with diabete mellitus), flatulence, gastroenteritis, GERD, gastritis, alopecia, lipase increase, amylase increase, injection site reaction, and hypotension. I also understand that if any serious reactions arise, such as thyroud disorder, I am responsible for notifying RevitaShotS, Sei Favolosa (Nurse Practitioner) and consulting my primary care provider immediately and/or proceeding to the nearest emergency department.

I understand that my entire patient history will remain completely confidential and will not be released without express written consent from me.