Semaglutide Injections for Weight Loss

Education and Consent for Weight Loss Treatment

The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure named above. This material serves as a supplement to the discussion you have with your doctor/healthcare provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form.

What is Semaglutide?

• Semaglutide is a weight loss medication received by weekly injection

How Does Semaglutide Work?
• Slows down stomach emptying so that after eating, you feel full longer
• Suppresses appetite & food cravings (on average patients eat ~30% less)
• Lowers blood glucose levels (without making glucose levels too low)

Your body naturally produces several substances that affect your appetite. One of these is called glucagon-like peptide-1 (GLP-1). The body produces GLP-1 naturally when you eat. GLP-1 stops you from feeling hungry and makes you feel full or satisfied. Semaglutide imitates GLP-1 in the body, which slows down stomach emptying, suppresses appetite and food cravings, and lowers blood glucose levels.

Reduced food intake: Because Semaglutide reduces feelings of hunger, you eat less food. When combined with a healthy diet and exercise, Semaglutide will help you lose weight.

Positive Effect on plaques in your blood vessels: In animal studies, Semaglutide stopped the progression of plaque formation in blood vessels. This is likely why Semaglutide has also been shown to reduce the risk of cardiovascular events and strokes.

Semaglutide Treats Obesity AND Decreases the Health Risks Caused by Obesity
Losing weight with Semaglutide may enable you to stop taking your antihypertensive medications, your lipid/cholesterol lowering drugs, and medications for glucose control.

Who Can Take Semaglutide?
Adult clients with an initial body mass index (BMI) of -
- 30 (kg/m2) or greater (obesity)
- 27 (kg/m2) or greater (overweight) in the presence of one weight related comorbidity (hypertension, type 2 diabetes, or dyslipidemia)

What Are the Ingredients in Semaglutide?
Active Ingredient: Semaglutide and L-Carnitine
Inactive Ingredients: disodium phosphate dihydrate, sodium chloride, and water for injection

What is L-Carnitine?
• L-Carnitine has also been studied to help with the treatment of is an amino acid that helps improve cellular energy. L-Carnitine may improve insulin sensitivity in diabetics by decreasing fat levels in muscle and may lower glucose levels in the blood by more promptly increasing its oxidation in cells.

Who Cannot Take Semaglutide?
You CANNOT take Semaglutide if you have any of the following conditions:
-Personal or family history of Medullary Thyroid Carcinoma (MTC)
-Personal or family history of Multiple Endocrine Neoplasia, type 2 (MEN2)
-Prior allergic reaction to Semaglutide or any of its ingredients (serious allergic reactions have been reported)
-Diabetic retinopathy (diabetic eye disease)
-Pregnant or trying to become pregnant/Breast feeding (the estimated background risk of major birth defects is ~3% and the estimated background risk of miscarriage is ~18% - these percentages are increased with use of Semaglutide during pregnancy)
-Less than 18 years old
-Depression with history of suicidal thoughts
-History of Pancreatitis (persistent severe abdominal pain, sometimes radiating to the back with or without vomiting)
- Kidney disease/Kidney insufficiency
-Stomach problems (Semaglutide will likely mske these problems worse)
-Diabetes (it is recommended that you see your endocrinologist or primary care physician as you could qualify for this treatment under your
medical insurance)

Lab Work Required:
-Basic Metabolic Panel (BMP) & Lipid Panel
This can be drawn at The DRIPBaR for an $80 blood draw fee paid to us and $65 paid to the lab or can be drawn at Quest or Lab Corp through your insurance
-Previous lab work can be used if it is within 90 days
-All labs are reviewed by the Medical Provider for approval to participate in the program.

Weekly Visits Required:

-Monitoring of vitals signs – BP, Heart Rate, Temp with each visit

- Weigh In for weight, BMI and body composition analysis

- Injection subcutaneously is administered once weekly by the RN, it is recommended it occur on the same day each week. This may occur at any time of the day, with or without meals. The day of weekly administration can be changed, if necessary, as long as the time between two doses is at least 3 days. After selecting a new dosing day, once-weekly dosing should be continued.

If a dose is missed, it should be administered as soon as possible if it is 5 days or less since you missed your last dose. If more than 5 days have passed, the missed dose should be skipped, and the next dose should be administered on the regularly scheduled day. In each case, the client can then resume their regular once weekly dosing schedule.

8-Week Program:
-Semaglutide dosage starts low, and slowly increases every 4 weeks based on your results and tolerance
-Most common side effects are constipation and nausea
-It is recommended that all clients also purchase a B12 shot each week to help increase energy especially since it plays a role in fat
- If you are already taking Semaglutide please contact us to discuss how to transition over The DRIPBaR’s program for details and pricing.


The DRIPBaR 8-week Starter Program is $600, with B12 Shots $760

(Dosing: 4 weeks at 1 unit / .25mg + 4 weeks at 2 units / .5mg)

The DRIPBaR offers packages beyond the 8-week starter program. Unit volume requires a quick approval from our medical provider.

- 4 weeks at 2 units / .5mg = $400

- 4 weeks at 4 units / 1.0mg = $600

- 4 weeks at 6 units / 1.5mg = $700

- 4 weeks at 8 units / 2.0 mg= $800

- 4 weeks at 10 units / 2/5,g = $1,000

  • Ask about our 16 week program for $2,000

MEMBERS SPECIAL: Receive complimentary blood draw for lab work and a B12 shot* for each week of your plan. *Members can substitute B12 for a B-complex

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