General Consent

Prior to starting my treatment with Healing Hands, I have and/or will fully disclose any and all medical conditions or diseases. If I fail to disclose any medical conditions that I have, I release the Provider and Healing Hands from any liability associated with this program.

I agree to immediately report any problems that may occur to my medical provider during the treatment program. I further understand that not complying with the dosage recommendations and dietary restrictions could increase risks. If I do not follow these recommendations and restrictions, I agree to release the provider and Healing Hands from any liability arising as a result of this. While adverse side effects or complications are not expected, in the event that an illness does occur, I understand that I need to contact Healing Hands immediately. If I experience an emergency situation, I understand that I need to go to an emergency facility.

I understand that if there are any changes in my medical history, or there are any changes in my medications or any other changes relevant to my weight loss program, I will advise Healing Hands at that time.

I give permission for photographs of the before and after photos of patients to be kept on file, and to be used for training purposes, and/or promotional purposes. Complete patient confidentiality will be maintained at all times.

I understand that I can be successful without the use of appetite suppressants or 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.

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, my subscription fee, every 4 weeks. This 28 day period includes any Provider consultation, staff support, and 4 weekly injections. I understand that there are NO refunds, and that I can cancel anytime prior to the next 4 week renewal. I also understand that these charges are not covered by my insurance and Healing Hands does not provide or fill out claim forms for insurance purposes.

Semaglutide & Tirzepatide Injection Consent

I understand my provider is recommending a prescription for the medication Semaglutide or Tirzepatide to facilitate and promote weight loss.

Serious side effects of taking this drug may include: prolonged vomiting, inflammation of your pancreas (pancreatitis), changes to vision, low blood sugar (hypoglycemia), kidney problems, and serious allergic reactions.

Common side effects may include nausea, vomitting, diarrhea, stomach pain, constipation and possible ileum.

I understand that I will be in charge of administering the prescribed drug and will conform with the recommended dosages and methods of administration provided by Healing Hands. Proper administration of injection instructions are available on our website.

I understand that I will be in charge of administering the prescribed drug and will conform with the recommended dosages and methods of administration provided by Healing Hands.

The drug provided to me is a compounded drug provided by a FDA Registered Drug Manufacturer and Licensed 503B. 503B Facilities are heavily regulated and monitored by the FDA.

I understand and have been advised that I should not receive Semaglutide or Tirzepatide if I have a history of angiodema, anaphylaxis or other serious hypersensitivity reaction to Semaglutide or Tirzepatide or if I am pregnant or breastfeeding.

Semaglutide and Tirzepatide is contraindicated in patients with a personal of family history of certain types of thyroid cancer, specifically thyroid C-cell tumors such as medullary thyroid carcinoma (MTC) or in patients with multiple endocrine neoplasia syndrome type 2 (MEN 2). It is also contraindicated in patients with type 1 diabetes and history of pancreatitis.

I understand, in studies, some laboratory animals given semaglutide or tirzepatide developed thyroid tumors, but it is not known if this medication increases the risk of tumors in humans.

Semaglutide and Tirzepatide should be used cautiously for people on other blood sugar lowering medications and you should limit the amount of alcohol intake while on this medication.

By signing below, I acknowledge that I am not presently suffering from any of the above conditions. I certify that I have read this form and that I understand its contents. I have been given the opportunity to ask questions about my condition, the medication to be used and the risks and side effects involved, as well as alternative treatments. I have sufficient information to give this informed consent.

I understand I am required to pay in full, at time of order, and every 28 days thereafter that I decide to continue my weight loss program, and that all fees and the medication is non-refundable and non-returnable.