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Weight Loss Terms and Conditions

Consent to Semaglutide Treatment

Before you choose to use the services of a practitioner: please read the following information FULLY AND CAREFULLY: 

Why Semaglutides injections? The main benefits may include: 

1. Semaglutide is 94% similar to natural human GLP-1 and therefore acts as a physiological regulator of appetite thereby reducing food intake by reducing feelings of hunger and increasing feelings of fullness/satiety. The exact underlying mechanism of action is 

2. Semaglutide is a newly licensed medication indicated for the treatment of type-2 diabetes. It is currently undergoing clinical trials to gain a license for the treatment of obesity. In the meantime, your medical practitioner may prescribe this medication for you 'off-label' 

3. For long-term success the treatment needs to be combined with lifestyle changes including nutritional, exercise, and behavioral habits. 

4. Weight loss can lead to secondary benefits by improving weight loss-related health problems such as cardiovascular risk factors (including hypertension, blood glucose levels, and waist circumference) and physical health-related Quality of Life. 

Patient understands that they have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until they have had an opportunity to receive such information and to give my informed consent. 

Since every human being is unique, we cannot guarantee any specific result from Semaglutide treatment. Medication and or medical conditions may have a negative impact on the outcomes as well as lifestyle factors. Patients need to follow the instructions carefully as provided separately in the patient instruction sheet. Patients must agree to notify their practitioner of any contraindications or side effects of the treatment. 

Upon request, we can write to your GP to notify them of the details of the program and any blood results (if completed)

HEALTH CONCERNS: If you suffer from a medical or pathological condition, you need to consult with an appropriate healthcare provider such as your GP or Consultant. If you are under the care of another healthcare provider, it is important that you inform your other healthcare providers of your use of Semaglutide. If you are using medications of any kind, you are required to alert us.

Note: If you have any physical or emotional reaction to Semaglutide treatment, discontinue use immediately, and contact your PRACTITIONER to ascertain if the reaction is adverse or an indication of the natural course of the body's adjustment to the treatment.

 

Laboratory testing may be done on any patient identified at risk to determine areas of dysfunction, not to diagnose or treat. Potential blood tests: 

• Full blood count 

• Liver function test

• Kidney Function Tests 

• Cholesterol levels, HbA1c, Glucose 

Patient groups who may require blood test monitoring at additional cost: (Age 50 or above)

• High blood pressure 

• Pre-Diabetics 

• Any significant medical problem 

 

COMMUNICATION: Every client is an individual, and it is not possible to determine in advance how your system will react to the treatment. It is sometimes necessary to adjust your program as we proceed. It is your responsibility to do your part by following healthy dietary guidelines, exercising your body, and making necessary behavioral modifications.

1. Alternatives to Semiglutide therapy are surgical procedures, oral medical treatments (including Orlistat), and/or dietary and lifestyle changes alone.

2. Several weeks to months of treatment may be required depending on your response.

3. If a missed dose is more than 5 days late, the missed dose should not be taken, and the next dose should be taken at the normal time.

4. It is essential to combine eating, exercise, and behavioral modifications with Semaglutide.

5. Semaglutide should not be used in combination with another GLP-1 receptor agonist, insulin, or insulin secretagogues (such as sulfonylureas) due to the risk of hypoglycemia.

6. Upon initiation of Semaglutide treatment in patients on warfarin or other coumarin derivatives more frequent monitoring of International Normalized Ratio (INR) is recommended.

7. Semaglutide causes a delay in gastric emptying and has the potential to impact the absorption of concomitantly administered oral medications. Monitor for potential consequences of delayed absorption of oral medications concomitantly administered with Semaglutide 

8. There are several special warnings and precautions for the use of Semaglutide including warnings on pancreatitis, cholelithiasis and cholecystitis, thyroid disease, heart rate, dehydration, and hypoglycemia in people with type 2 diabetes. 

9. Thyroid adverse events, such as goiter have been reported in particular in patients with pre-existing thyroid disease. Semaglutide should therefore be used with caution in patients with thyroid disease. 

10. A higher rate of cholelithiasis and cholecystitis (gallstone and gallbladder disease) has been observed in patients treated with semaglutide. Cholelithiasis and cholecystitis may lead to hospitalization and cholecystectomy (surgery to remove the gallbladder Patients should be aware of the characteristic symptoms of cholelithiasis and cholecystitis.

11. Signs and symptoms of dehydration, including renal impairment and acute renal failure, have been reported in patients treated with Semaglutide. Patients treated with semaglutide should be advised of the potential risk of dehydration in relation to gastrointestinal side effects and take precautions to avoid fluid depletion. Patients should also be aware of the symptoms of increased heart rate. 

12. Acute pancreatitis has been observed with the use of Semaglutide. Patients and their carers should be told how to recognize signs and symptoms of acute pancreatitis and advised to seek immediate medical attention if symptoms develop. If pancreatitis is suspected, semaglutide should be discontinued; if acute pancreatitis is confirmed, semaglutide should not be restarted. 

13. Semaglutide may cause dose-dependent and Treatment-duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Semaglutide causes thyroid C-cell tumors, including medullary thyroid carcinoma (cancer, MTC), in humans, as the human relevance of semaglutide-induced rodent thyroid C-cell tumors has not been determined. Patients should be aware of symptoms of thyroid tumors (such as a mass in the neck, difficulty swallowing, difficulty breathing or shortness of breath, persistent hoarseness 

 

The most common Semaglutide side effects are: 

• Nausea 

• Constipation 

• Decreased appetite 

• Dizziness 

• Hypoglycemia 

• Vomiting 

• Dyspepsia 

• Abdominal pain 

• Diarrhea 

• Headache 

• Fatigue 

• Increased lipase

 

Nausea is the most common side effect when first starting Semaglutide or Tirzepitides but decreases over time for most people as their body gets used to the medicine. The dosing schedule is designed to reduce the likelihood of gastrointestinal symptoms. Tell your healthcare professional if you have any side effect that bothers you or that does not go away. 

Risks of Semaglutide  treatment include but are not limited to:

a. Common or very common, reported in 5%: Dysgeusia (altered sense of taste), dry mouth, insomnia, asthenia; burping; constipation; diarrhea; dizziness; dry mouth; gallbladder disorders; gastrointestinal discomfort; gastrointestinal disorders; insomnia; nausea; vomiting, hypoglycaemia, dyspepsia, gastritis, gastro-oesophageal reflux disease, flatulence, eructation, upper abdomen pain, abdomen distension, cholelithiasis, injection site reactions, fatigue, increased lipase and increased amylase. 

b. Uncommon: Malaise; pancreatitis; tachycardia; urticaria 

c. Rare: Renal impairment, allergic reaction, anaphylaxis

Do not take Semaglutide if any of the below contraindications apply to you: 

a. Aged under 18 or above 75

b. Severe renal/kidney impairment (with eGFR of 15 or below) or a history of renal disease

c. Severe hepatic/liver impairment

d. Personal or family history of medullary thyroid cancer (MTC)

e. Hypersensitivity to Semaglutide or to any of the excipients: disodium phosphate dihydrate, propylene glycol, phenol and water for injection

f. Concurrent treatment with any other products for weight management

g. Weight problems related to endocrinological or eating disorders

h.  Concurrent insulin or sulfonylurea 

i. Patients on warfarin (more frequent INR monitoring required)

j. Concurrent use of any medicinal products may cause weight gain

k. Pregnancy, breastfeeding or trying to/planning to become pregnant. Congestive heart failure 

m. History of pancreatitis, gallbladder disease, inflammatory bowel disease, diabetic gastroparesis. 

The below drugs interact with Semaglutide and treatment of Semaglutide should not be used concurrently. Drug interactions: 

  • Alogliptin 

  • Biphasic insulin aspart 

  • Biphasic insulin lispro 

  • Biphasic isophane insulin 

  • Canagliflozin 

  • Dapagliflozin 

  • Dulaglutide 

  • Empagliflozin 

  • Exenatide 

  • Glibenclamide 

  • Gliclazide 

  • Glimepiride 

  • Glipizide

  • Any insulin including aspart, degludec, detemir, glargine, glulisine, lispro, isophane, zinc suspension

  • Nateglinide 

  • Pioglitazone 

  • Repaglinide Saxagliptin, Sitagliptin, Vildagliptin 

  • Tolbutamide 


(A) WARNING: RAPID WEIGHT LOSS MAY CAUSE SERIOUS HEALTH PROBLEMS. RAPID WEIGHT LOSS IS WEIGHT LOSS OF MORE THAN 1.5 POUNDS TO 2 POUNDS PER WEEK OR WEIGHT LOSS OF MORE THAN 1 PERCENT OF BODY WEIGHT PER WEEK AFTER THE SECOND WEEK OF PARTICIPATION IN A WEIGHT-LOSS PROGRAM.

(B) CONSULT YOUR PERSONAL PHYSICIAN BEFORE STARTING ANY WEIGHT-LOSS PROGRAM.

(C) ONLY PERMANENT LIFESTYLE CHANGES, SUCH AS MAKING HEALTHFUL FOOD CHOICES AND INCREASING PHYSICAL ACTIVITY, PROMOTE LONG-TERM WEIGHT LOSS.

(D) QUALIFICATIONS OF THIS PROVIDER ARE AVAILABLE UPON REQUEST.

(E) YOU HAVE A RIGHT TO: ASK QUESTIONS ABOUT THE POTENTIAL HEALTH RISKS OF THIS PROGRAM AND ITS NUTRITIONAL CONTENT, PSYCHOLOGICAL SUPPORT, AND EDUCATIONAL COMPONENTS. RECEIVE AN ITEMIZED STATEMENT OF THE ACTUAL OR ESTIMATED PRICE OF THE WEIGHT-LOSS PROGRAM, INCLUDING EXTRA PRODUCTS, SERVICES, SUPPLEMENTS, EXAMINATIONS, AND LABORATORY TESTS. KNOW THE ACTUAL OR ESTIMATED DURATION OF THE PROGRAM. KNOW THE NAME, ADDRESS, AND QUALIFICATIONS OF THE PHYSICIAN, DIETITIAN OR NUTRITIONIST WHO HAS REVIEWED AND APPROVED THE WEIGHT-LOSS PROGRAM ACCORDING TO s. 468.505(1) (j), FLORIDA STATUTES.

Potential Risks and Side Effects: HCG will NOT be prescribed and is contraindicated if: You are pregnant, trying to become pregnant, or currently breastfeeding. You have ever had any type of cancer or malignancy? You have Undiagnosed Uterine Bleeding. You have heart disease, a history of a heart attack, stroke, bleeding disorder, or blood clot. You are an Insulin-Dependent Diabetic (Individual Dependent)

You must inform your primary health care provider or seek immediate medical attention (as indicated) if any of the following occurs:

Allergic Reactions: If you experience a reaction to the injection, you may have sensitivity to HCG. Stop using HCG and seek medical attention immediately.

It is necessary for you to disclose any pre-existing condition in order to rule out any symptomatology that may not be related to the HCG. Also during an allergic reaction, the body produces excess fibrin which induces blood clotting, a potentially lethal situation.

Less serious side effects may occur and include: headache (often during the first week only); Feeling restless, irritable or fatigued (often during the first week only); Constipation; Increased urination; Mood swings (often during the first week only); Breast tenderness or swelling; Pain, swelling, redness, bruising or irritation where the injection is given; In some patients, temporary hair loss may occur as a result of rapid weight loss.

Other Drugs May Affect HCG

There may be other drugs that can interact with HCG. Tell us about all prescription medication over-the-counter medications, vitamins and any type of supplements you presently use. Do not start taking any new medications or supplements without telling us. The use of steroids or antibiotics while on the program may reduce effectiveness and dramatically slow weight loss.

FDA Disclaimers and Required Communication to Patients

"The FDA has not approved HCG Therapy to lose weight. "HCG HAS NOT BEEN DEMONSTRATED TO BE EFFECTIVE ADJUNCTIVE THERAPY IN THE TREATMENT OF OBESITY. THERE IS NO SUBSTANTIAL EVIDENCE (although some positive research does exist) THAT IT INCREASES WEIGHT LOSS BEYOND THAT RESULTING FROM CALORIC RESTRICTION, THAT IT CAUSES A MORE ATTRACTIVE OR "NORMAL" DISTRIBUTION OF FAT, OR THAT IT DECREASES THE HUNGER AND DISCOMFORT ASSOCIATED WITH CALORIE-RESTRICTED DIETS.

Patients must understand that this diet protocol includes "off---label" use of the FDA-approved medication HCG Human Chorionic Gonadotropin. patient understands that this medication has not been approved for the purpose of weight loss but is approved by the FDA for other medical treatments. These treatments are approved for young boys or adult men with a condition of Hyper-Gonadism and in women as an aid in achieving pregnancy.

FDA understands that sometimes approved products are used to treat conditions that the products were not approved for (i.e., "off-label" uses). The "off-label" use of products usually presents greater uncertainty about both the risks and benefits because less information is available on safety and effectiveness. Unexpected adverse events may occur in this context. . ("Off---label" use means the use of FDA-approved drugs for purposes other than those for which the FDA has approved them.) "Off---label" prescribing is a legal and common practice by physicians in the United States.

Professional Evren Health Weight Loss Telehealth HIPAA Notice of Privacy Practice
This describes how your information may be disclosed and how you get access to this information. This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment, and healthcare operations, and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected Health Information, or PHI is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related healthcare services. Uses and Disclosures of Protected Health Information Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office who are involved in your care and treatment to provide health care services to you, to pay your health care bills, to support the operations of the physician's practice, and any other use required by law. 

Treatment: We will only use and disclose your protected health information to provide, coordinate, or manage your health care and related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides you care or provide it to a physician whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. 

Payment: Your protected health information will be used as needed to obtain payment for your health care services. 

Healthcare Operations: We may use or disclose, as needed, your protected health information to support the business activities of your physician's practice. These activities include but are not limited to quality assessment, employee review, training of medical students, and licensing. For example, we may call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointments. We may use or disclose your protected health information in the following situations without your authorization: as required by law, public health issues, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity, and national security. Under the law, we must also make disclosures to you, when required by the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500. Other Permitted and Required Uses and Disclosures will be made only with your authorization or opportunity to object unless required by law. You may revoke this authorization at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization. 

 

Your Individual Rights: 

1. You have the right to inspect and receive a copy of your protected health information. Our practice will accept such requests in writing. Under federal law, however, you may not inspect or receive a copy of the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in a civil, criminal, or administrative action or proceeding; and protected health information that is subject to law that prohibits access to protected health information. 

2. You have the right to request a restriction on the disclosure of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If a physician believes it is in your best interest to permit the use and disclosure of our protected health information, your health information will not be restricted. You then have the right to use another healthcare professional. 

3. You have the right to request to receive confidential communications from us by an alternative means or at an alternative location.

4. You have the right to obtain a paper copy of this notice from us. 

5. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will post any changes in our waiting areas. You then have the right to object as provided in this notice. 

Complaints: You may file any complaints with our Office Management at info@evrenhealth.com or with the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. We will not retaliate against you for filing a complaint. Evren, LLC Receipt of Notice of Privacy Practices Evren, LLC reserves the right to modify the privacy practices outlined in this notice. By signing our consent, you are indicating that you have read and understand the Notice of Privacy practices. FDA urges both healthcare professionals and consumers to report harmful effects experienced from using HCG for weight loss to the FDA's Med Watch Adverse Event Reporting program by doing one of the following:

  1. Complete and submit the report online: www.fda.gov/MedWatch/report.htm

  2. Download the form or call 1-800-332-1088 to request a reporting form, then complete and return it to the address on the pre-addressed form, or submit by fax to 1-800-FDA-0178

Financial Policy
Please be advised that payment is due in full before starting the program. If paying with Credit or Debit, your charge will be from Evren, LLC. DBA Evren Health Weight Loss, is a licensed clinic in Pompano Beach, FL specializing in weight loss consulting and programs. There is no warranty or guarantee of results due largely to off-site administration and patient-controlled application of the diet program. Should this account be referred to an agency or an attorney for collection, you will be responsible for all collection costs, attorney's fees, and court costs. By submitting our intake form and moving forward with any order paid by credit or debit card, you agree that any credit or debit card dispute should be resolved in favor of Evren, LLC DBA Even Health Weight Loss. By signing our intake and consent forms, you are acknowledging that you have read and agree to our Financial Policy. We have a no refund policy and office use or prescribed medications cannot be returned. Our fees include consultation, order processing, costs of medications prescribed, and cost of supplies.

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