Weight Loss Injections Telemedicine Intake Form

Through telemedicine, Dr. Straface can offer convenient and affordable healthcare services to patients. Telemedicine is an excellent option for non-emergency situations. Please read the below information below about weight loss injections and fill out the questionnaire with as accurate information as possible.

Please read these terms carefully and agree to the terms below.

Human-based glucagon-like peptide-1 receptor agonists (GLP-1 RA) such as Semaglutude (compounded), Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy® Mounjaro® are prescribed as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) that is considered outside a healthy range.

While using a GLP-1 RA it is highly recommended that you:

Eat a fibrous diet. Focus on fruits and vegetables that are high in fiber
Eat small high-protein meals as digestion is slowed down while on this medication
Avoid foods high in fat as they take longer to digest
Drink at least 32oz of water a day to avoid constipation

Do not take this medication if:

You have a personal or family history of medullary thyroid carcinoma (Thyroid Cancer)
You have a personal history of Multiple Endocrine Neoplasia syndrome type 2 (MEN2)
You are pregnant or plan to become pregnant while taking this medicine
You are diabetic and taking any medications related to lowering your blood sugar levels without speaking with your endocrinologist or primary care provider. Specifically, if you are prescribed Insulin because the combination may increase your risk of hypoglycemia (low blood sugar) and dosage adjustments by your provider may be necessary.
You are allergic to Semaglutide or any other GLP-1 agonist such as: Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy® Mounjaro® (THIS IS NOT AN ALL-INCLUSIVE LIST)

Possible drug interactions:

Anti-diabetic agents, specifically insulin and sulfonylureas (e.g., glyburide, glipizide, glimepiride, tolbutamide) due to the increased risk of hypoglycemia (low blood sugar). Do not take with other GLP-1 agonist medicines such as: Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy® Maunjaro® (THIS IS NOT AN ALL-INCLUSIVE LIST).
Blood pressure medications: As weight loss may occur on this medication, it is imperative to monitor your blood pressure at home while on this medication and take blood pressure medication at the same time. Weight loss may naturally decrease your blood pressure, which may make it necessary to adjust your blood pressure medication dosage. As weight loss occurs, it is recommended to keep a blood pressure diary.

Possible side effects:

Nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dyspepsia, dizziness, abdominal distension, belching, hypoglycemia, flatulence, gastroenteritis, and gastroesophageal reflux disease.
Possible side effects of subcutaneous injections: itching or burning at the site of administration with or without thickening of the skin.

If you notice other side effects not listed above, contact your healthcare provider. A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, or trouble breathing.

GLP-1 RA may cause other serious issues such as possible thyroid tumors, including cancer. Tell your healthcare provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. In studies with rodents, Semaglutide caused thyroid tumors, including thyroid cancer. It is not known if Semaglutide/ GLP-1 RA will cause thyroid tumors or a type of thyroid cancer called medullary thyroid carcinoma (MTC) in people.

Report adverse side effects to your clinician. In the event of any emergency, call 911 immediately.

IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THIS TREATMENT, OR ANY QUESTIONS CONCERNING THIS PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK DR. STRAFACE BEFORE BEGINNING TREATMENT.

By signing, I certify that I have read and understand the contents of this form. I am aware of the possible side effects and drug interactions. If deemed a candidate for treatment, I give my consent for treatment. I have informed the medical staff of any known allergies to drugs or other substances, and any past adverse reactions I’ve experienced. I have informed the medical staff of all medications and supplements I’m currently taking. I understand there are other ways and programs that can assist me in my desire to decrease my body weight and acknowledge that no guarantees have been made to me concerning my results.

This consent covers the initial and all future prescriptions for this medication.

I understand that this is a prescription therapy and is not eligible for a refund or reimbursement.

I consent to this service being provided by an employee at Feel Ideal 360.

I have read and agree to the above. I will address all questions and concerns with Dr. Straface prior to beginning treatment. I will have an understanding of the treatment and goals prior to beginning treatment. I understand and accept the potential risks associated with GLP-1 RA therapy as stated above and consent to treatment.

Please check below:

I agree

I agree to release Dr. Straface and all her associates from all medical liability and malpractice claims related to any and all care, including but not limited to weight loss treatment or injections.

Please check below:

I agree

I have read through all the above information and if I have questions I will ask the doctor.

Please check below:

I agree

I certify that I have been informed of the risks and benefits of treatment.

Please check below:

I agree

I will review the side effects of all medications I am prescribed and immediately inform the doctor of any side effects.

Please check below:

I agree

First Name

Last Name

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Date of birth:

Height

Current weight

Upload a dated photos of your current weight:

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Current blood pressure

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Prior surgeries?

Do you have a known heart condition?

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If yes, please explain your heart conditions:

Do you have a family history of heart conditions?

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If yes, please explain your family history of heart conditions:

Do you have a personal medical history involving any of the following medical conditions: Diabetes Mellitus, Diabetic Retinopathy, Diabetic Ketoacidosis, Pancreatitis, Gallbladder Disease, Medullary Thyroid Carcinoma, Multiple Endocrine Neoplasia, Kidney Disease, Kidney Insufficiency, or stomach problems?

Choose one below:

If yes, please explain:

Are you currently pregnant, trying to get pregnant, or breast feeding?

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Are you currently experiencing or have you experienced depression with a history of suicidal attempts, suicidal thoughts, or suicidal ideation?

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Do you have a family history of Multiple Endocrine Neoplasia, Type 2, (MEN 2) or Medullary Thyroid Carcinoma (MTC)?

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Are you currently receiving chemotherapy?

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Are you taking any medication? If yes, please list them:

Any allergies to medications?

Have you ever had an adverse or allergic reaction to semaglutide, or to any of its ingredients such as vitamin B12?

Please choose one below:

Have you ever had an adverse or allergic reaction to another GLP-1 receptor such as, but without limitation to, Dulaglutide (Trulicity), Exenatide extended release (Bydureon BCise), Exenatide (Byetta), Liraglutide (Victoza, Saxenda), or Lixisenatide (Adylyxin)?

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Pharmacy name

Pharmacy phone:

Pharmacy fax number:

How did you hear about us?

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Referral

Who referred you so that we can thank them for their awesome support?

Medical Disclaimer

Patient agrees to virtual e-visit service terms, privacy policy, and charge for receiving a virtual visit from Dr. Straface at Feel Ideal 360. After reviewing your information, or during the e-visit it may be determined that your problem is too complex for an e-visit session. In that case our office will schedule you for a traditional office visit and your e-visit fee will be applied to the patient balance related to your office visit. Our physician appropriately documents the virtual e-visit, including all pertinent communication related to the encounter, in the patient’s medical/health record. The physician has a defined period of time within which responses to a virtual e-visit request are completed. During the virtual e-visit, the physician may make recommendations, provide medical advice and/or prescribe, refill or recommend medications. The physician may suggest the patient receive additional care, examination, testing and/or treatment at a medical facility in-person. If necessary, the physician may also suggest that the patient receive care in an emergency room. Communication during an e-visit may be exchanged via teleconference, landline phone, cellular phone and online chat per the State of Texas. By requesting an e-visit you acknowledge that personal health information will be communicated. A virtual e-visit may include the total interchange of online inquiries and other communications associated with this single patient encounter, subject to determination of the physician. As with any medical service, decision, or treatment, there are risks; and, an e-visit is no different. Because this visit is electronic and not in person, you acknowledge that the risk may be greater than a traditional office visit, and by requesting the visit you agree to accept the outcome-even if it is undesirable. In addition, you agree to abide by our office's routine policies including any policy related to litigation. I acknowledge I am paying for a telemedicine consult with the physician and the outcome will be based solely on the physician's medical discretion and the fee is non-refundable.

Signature

I acknowledge and agree that I have read the Medical Disclaimer above and I am authorizing Dr. Straface to proceed with our telemedicine visit.

Date

Important:

You may inquire with your own insurance company about reimbursement. We do not take insurance at this time.
The consultation fee does not include the cost of the medication prescribed.
Also, if you are experiencing any technical difficulties with our automated processing form above please contact our office directly and one of our Feel Ideal 360 Team members will assist. Thank you! Phone: 972-656-1200

In the event that my treatment plan includes shipped material, I understand Feel Ideal 360 is adding insurance to my order through USPS or FedEx to cover the cost of any loss or damage to my order while shipping. If my package is damaged, lost, or stolen, I will file a claim with USPS for financial reimbursement. Feel Ideal 360 is NOT responsible for delayed, damaged, lost, or stolen packages, and will NOT be reshipping delayed, damaged, lost, or stolen packages at this time.

Please check the box below to agree:

I agree

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Sub Total

$125.00

TOTAL

$125.00

Payment Method

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Weight Loss Injections Telemedicine Intake Form

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