Name: Skinly Aesthetics
Price range: $

Name(Required)

First Last

Date ff Birth(Required)

Sex(Required)

Male

Female

Phone Number(Required)

Email Address(Required)

Are you here to be evaluated for weight loss?(Required)

Yes

No

Do you have any of the following medical problems?(Required)

Cirrhosis/liver disease

End stage renal failure

None of the above

Do you have any of the following medical problems?(Required)

Have you ever attempted to lose weight through a weight management program longer than 6 months?(Required)

Yes

No

Are you willing to reduce your caloric intake alongside medication?(Required)

Yes

No

Are you willing to increase your physical activity alongside medication?(Required)

Yes

No

Have you ever dealt with following:(Required)

Anorexia nervosa

Bulimia nervosa

None of the above

Are you taking any medications?(Required)

Yes

No

Current Medications:(Required)

Please list the generic name of your medication, the dose, how many times per day, how long you have been on this medication.

Did you ever have any type of thyroid cancer?(Required)

Yes

No

Please type the thyroid cancer type/s you have or had?(Required)

Do you have any allergies to medications?(Required)

Yes

No

List your medication allergies(Required)

What is your goal weight?(Required)

Current Weight (lb)(Required)

Height(Required)

Please provide a recent blood pressure measurement within the last 6 months, which should be listed as follows: Systolic (top number)/Diastolic (bottom number)(Required)

If you are not sure, please go have your blood pressure obtained (typically free at your local pharmacy).

Are you pregnant or expecting to be?(Required)

Pregnant

Breastfeeding or lactating

Expecting to be pregnant

No or Doesn’t apply

Where do you live?

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Photo of Your Drivers License(Required)

Accepted file types: jpg, jpeg, png, pdf, heic, raw, Max. file size: 50 MB.

Your photo in active wear or swimsuit(Required)

Accepted file types: jpg, jpeg, png, pdf, heic, raw, Max. file size: 50 MB.

Untitled(Required)

By checking the box below I understand that I will be charged a monthly enrollment fee as part of my contract that will be provided to me in a separate document.

Introduction and Prescription Processing

Thank you for completing the consultation and responding to my questions. Based on our evaluation, you are approved to begin GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide) therapy for weight management.

Your prescription has been sent to the pharmacy and should ship within approximately five (5) business days.
You will receive a FedEx tracking notification when your prescription ships.
GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide) must remain refrigerated upon arrival. Please closely track your shipment and refrigerate your medication immediately upon delivery.
If you have any concerns regarding shipping, billing, or changes to your subscription, please contact our customer support team at: info@skinlyaesthetics.com.

Instructions for Administration of GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide)

GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide) will be administered via subcutaneous injection, typically in the abdomen, thigh, or upper arm.

You will be provided with an exact dosing regimen based on your prescription.

Important dosage note:

If you experience side effects at the lower dose and do not wish to escalate to the higher dosage, it is completely acceptable to remain at the lower dose.
DO NOT EXCEED the number of units per week unless expressly instructed otherwise by your healthcare provider.

Medication Storage

Store your medication in the refrigerator between 36°F to 46°F (2°C to 8°C).
Keep the vial in its original packaging to reference dosing instructions and to avoid accidental disposal.
Do not freeze or expose medication to heat or direct sunlight.

Follow-Up and Support

You will be contacted for a follow-up within approximately four (4) weeks.
If you have not heard from us and you do not have sufficient medication for continued therapy, please proactively contact our support at: info@skinlyaesthetics.com.

Emergency Situations

If you experience a medical emergency, please dial 911 immediately or go to your nearest Emergency Room.
You may message your prescribing doctor directly, but please note there may be a response delay of 12-24 hours.

Risks and Precautions of GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide) Treatment

While GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide) can be effective for weight loss and diabetes management, it carries certain potential risks and side effects:

Thyroid Tumors: GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide) and related GLP-1 medications have been associated with thyroid tumors in laboratory animals. It remains unknown if GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide) poses a similar risk in humans.
Immediately notify your provider and stop taking GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide) if you experience:
- Lump, swelling, or mass in the neck area
- Persistent hoarseness
- Persistent pain or difficulty swallowing
Reproductive Precautions:
- Females of reproductive potential who use oral hormonal contraceptives should switch to non-oral contraceptive methods or use barrier methods for four weeks after initiating GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide) and four weeks following each dosage escalation.
- Please inform us immediately if you become pregnant, are breastfeeding, or are planning to conceive during your therapy. GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide) is contraindicated in pregnancy, breastfeeding, or planned pregnancy.

Benefits of GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide)

Clinical trials show an average weight loss of approximately 7% of initial body weight (13 lbs average) after 40 weeks, with continued weight loss (35 lbs average after 52 weeks).
Clinical studies indicate GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide) can reduce A1C levels by approximately 7% over treatment duration, improving glycemic control.
Weight-loss efficacy is optimized with consistent dietary management and regular exercise.

Important Note:
Results may vary and are not guaranteed. Each patient's experience depends on factors such as metabolism, adherence to treatment, diet, exercise, and other individual conditions.

Who Should NOT Take GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide)

Please review the following conditions carefully. Patients with the following conditions should NOT begin or continue GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide) therapy:

Personal or family history of medullary thyroid carcinoma (MTC) or multiple endocrine neoplasia syndrome type 2 (MEN-2)
History of pancreatitis
Eating disorders
Alcohol or substance abuse
Gallbladder disease (excluding those with gallbladder removal surgery)
Recent bariatric surgery
Retinopathy or severe vision problems
Pregnancy, breastfeeding, or actively planning pregnancy

Please notify us immediately if you develop any of the above conditions during your therapy.

Common Side Effects

GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide) treatment can cause certain side effects, especially in the first few weeks. These side effects typically improve with continued use but please inform us promptly if they persist or worsen:

Nausea (common at therapy initiation; generic Zofran [Ondansetron] may be prescribed as needed)
Abdominal pain or discomfort
Headaches
Fatigue
Diarrhea or constipation
Dizziness
Heartburn or upset stomach

IMPORTANT: If side effects feel severe or if you suspect a medical emergency, please call 911 immediately or seek urgent medical attention at an emergency room.

When to Stop GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide) Therapy

GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide) therapy is not indefinite. Therapy should be discontinued under the following circumstances:

Achieving your goal weight (set at the start of therapy)
Upon your doctor's recommendation
After 12 months of consistent use (unless otherwise indicated by your provider)
Significant, persistent, or concerning side effects

Note: It is crucial to maintain healthy lifestyle habits following cessation of GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide) to sustain weight loss results.

Regarding Compounded GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide)

Please understand that compounded medications are not FDA-approved. Although compounding can offer improved access and affordability, compounded medications might have variability in potency or efficacy.
As your physician, I hold no affiliation with any particular pharmacy. You retain the right to select any pharmacy for your prescription fulfillment.
Learn more about compounded medication here: [https://www.fda.gov/drugs/human-drug-compounding/compounding-and-fda-questions-and-answers].

Coordination of Care

We strongly encourage you to notify your primary care physician of your participation in this weight management program and GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide) therapy.

Patient Acknowledgement and Consent

By signing below, I acknowledge and affirm that:

I have read, understood, and had ample opportunity to ask questions regarding the above information and my GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide) treatment.
All my questions have been answered to my satisfaction.
I understand the potential risks, side effects, contraindications, and alternatives to GLP-1 (Semaglutide, Tirzepatide, Liraglutide, Retatrutide) therapy.
I understand that individual results are not guaranteed, and results may vary.
I will inform my provider promptly if my medical status, pregnancy status, or health conditions change.

This document serves as informed consent and should be retained for your records. If you have any additional questions, please contact our support team at: info@skinlyaesthetics.com.

Thank you, and welcome to your personalized weight management journey.

Signature(Required)

I consent to above terms. Please write your name and sign.

Semaglutide assessment form