MSB Weight Loss Form





Address Line:

Do you have a current Primary Care Physician? If yes, please list their name below:

Primary Care Physician:

Do you have allergies to any medicine? If yes, please list them below:

Please list out all allergies:

Are you currently taking any medication?

Please list your current medications:

Do you have a history of heart disease? Diabetes? Kidney disease? Thyroid disease? Autoimmune disease? Or any other chronic disease?

Please explain the history of any diseases you have:

Do you have a family history of Pancreatitis? 

Do you have a family history of thyroid cancer?  

Do you have a family history of Multiple Endocrine Neoplasia?

Have you ever taken weight loss medication?

If yes, explain when and what below:

What is your height?

What is your current weight?

What is your lowest adult weight?

What is your goal weight?

Are you actively pregnant?

Are you actively attempting to become pregnant?

Are you attempting to become pregnant within the next 3 months?



Semaglutide is a human-based glucagon-like peptide-1 receptor agonist 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 Semaglutide, 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
  • Limit alcohol intake as this medication can lower blood pressure
  • Drink at least 64oz 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)
  • Multiple Endocrine Neoplasia syndrome type 2 
  • You are pregnant or plan to become pregnant while taking this medicine
  • You are diabetic and/or taking any medications related to lowering your blood sugar levels without speaking with your endocrinologist.
  • 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 have a history of Pancreatitis • You are allergic to L-CARNITINE, Vitamin B12, Semaglutide or any other GLP-1 agonist such as: Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy®;
  • If you have other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details. Before using this medication, tell your doctor/pharmacist your medical history.

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® (THIS IS NOT AN ALL-INCLUSIVE LIST). Other medications used in diabetes, please tell your provider about any medications that may lower your blood sugar.

Possible side effects: Nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dyspepsia, dizziness, abdominal distension, belching, hypoglycemia, flatulence, gastroenteritis, and gastroesophageal reflux disease. Subcutaneous Injections: common injection site reactions characterized by itching, burning at site of administration with or without thickening of the skin(welting). If you notice other side effects not listed above, contact your doctor or pharmacist.

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, trouble breathing. Report adverse side effects to your doctor or pharmacist. In the event of any emergency, call 911 immediately.

Cancellation and Refund Policy: As the weight loss program offered by Icon Anti-Aging and Aesthetics PLLC involves prescription medications, it is important to note that these medications are non-refundable and non-returnable due to their nature as prescription items. By participating in our weight loss program, the patient acknowledges and agrees that there is no cancellation policy in place, and no refunds will be issued.

Outcome Guarantees: The patient understands and acknowledges that there are no guarantees for outcomes in the weight loss program. Results may vary from person to person, and individual factors can influence the effectiveness of the program.

No Promises Made: The patient agrees and understands that no promises or guarantees are made regarding the specific results or achievements in the weight loss program. The success of the program depends on various factors, including individual commitment and adherence to the prescribed plan.

Payment Responsibility: By enrolling in our weight loss program, the patient agrees and understands that they are responsible for making payments for the entire duration and terms of their membership. Failure to make timely payments may result in consequences outlined in this policy.

Collections for Missed Payments: In the event of a missed payment, the patient acknowledges and agrees that the outstanding amount will be sent to collections 90 days after the payment was due. Icon Anti-Aging and Aesthetics PLLC reserves the right to pursue collection efforts to recover any unpaid balances.

By signing below, the patient acknowledges that they have read, understood, and agreed to the terms and conditions outlined in this Weight Loss Membership Cancellation Policy.

By also 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 and 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.

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Signature Certificate
Document name: MSB Weight Loss Form
lock iconUnique Document ID: 8d03a7cc7e4784e95bd69c2abc5bdd2e135369e6
Timestamp Audit
June 13, 2023 9:38 pm EDTMSB Weight Loss Form Uploaded by Dr. Alex Zayid - [email protected] IP