Weight Loss Consent Form

I, having been fully informed, consent for Patient, which may be defined as me, my child, or a person for whom I have legal responsibility, to receive weight loss medications/treatments from Mr. Injection, LLC (the “Practice”) and the Practice’s providers and assistants.

All medical and cosmetic procedures carry risks and may cause complications. The purpose of this informed consent is to make you aware of the nature of these treatments and the associated risks in advance so that you may decide whether or not to undergo this procedure.

Disclaimer: At Mr. Injection we are prescribing a compounded medication known as Semaglutide/Tirzepatide/Retatrutide along with Vitamin B-12, Vitamin B-6 and also MIC-B12. Semaglutide/Tirzepatide/Retatrutide is an injectable prescription medication used for adults with obesity (BMI ≥30) or overweight (BMI ≥27) who also have weight-related medical problems to help them lose weight and keep the weight off.

● Semaglutide/Tirzepatide/Retatrutide should not be used with other

Semaglutide/Tirzepatide/Retatrutide containing products or other GLP-1 receptor agonist medications.

● Semaglutide/Tirzepatide/Retatrutide should be used with a reduced calorie meal plan and increased physical activity for best results.

● It is not known if Semaglutide/Tirzepatide/Retatrutide is safe and effective when taken with other prescription, herbal, or over-the-counter weight loss medications.

● It is not known if Semaglutide/Tirzepatide/Retatrutide is safe to use for someone with a history of pancreatitis.

● It is currently being studied, but not known if it is safe or effective for use in children under18 years of age.

Do not use Semaglutide/Tirzepatide/Retatrutide if:

● Patient or any of Patient’s family have ever had a type of thyroid cancer called medullary thyroid carcinoma (MTC) or if you have an endocrine system condition called Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).

● Patient has had a serious allergic reaction to Semaglutide/Tirzepatide/Retatrutide or any of the ingredients in Semaglutide/Tirzepatide/Retatrutide.

Before using Semaglutide/Tirzepatide/Retatrutide, tell your healthcare provider if Patient currently has,

or has a history of, any other medical conditions including:

● Pancreas or kidney disease.

● Diabetic retinopathy.

● Depression, suicidal thoughts, or mental health conditions.

● Pregnant or plan to become pregnant. (Semaglutide/Tirzepatide/Retatrutide may harm your unborn baby).

○ Patient should stop using Semaglutide/Tirzepatide/Retatrutide 2 months before Patient plans to become pregnant.

● Breastfeeding or plan to breastfeed. It is not known if Semaglutide Tirzepatide Retatrutide passes onto your child through your breast milk.

Tell your healthcare provider about all of the medications Patient takes, including prescription, over-the-counter, vitamins, and herbal supplements. Semaglutide/Tirzepatide/Retatrutide may affect the way some medications work and some medications may affect the way Semaglutide/Tirzepatide/Retatrutide works. Tell Patient’s healthcare provider if Patient is taking other medications to treat diabetes, including sulfonylureas or insulin. Semaglutide/Tirzepatide/Retatrutide

slows stomach emptying and can affect medications that need to pass through the stomach quickly.

The most common side effects of Semaglutide/Tirzepatide/Retatrutide may include:

● Nausea, heartburn, diarrhea, constipation, stomach pain, headache, fatigue, exercise intolerance, upset stomach, dizziness, bloating, belching, and gas.

Semaglutide/Tirzepatide/Retatrutide may cause serious side effects, including:

● Inflammation of the pancreas (pancreatitis). Stop using Semaglutide/Tirzepatide/Retatrutide and call your healthcare provider right away if Patient

has severe pain in the stomach area (abdomen) that will not go away, with or without vomiting. Patient may feel the pain from Patient’s abdomen to Patient’s back.

● Gallbladder problems. Semaglutide/Tirzepatide/Retatrutide may cause gallbladder problems, including gallstones. Some gallstones may need surgery. Call your healthcare provider if Patient has symptoms, such as pain in your upper stomach (abdomen), fever, yellowing of the skin or eyes (jaundice), or clay-colored stools.

● Increased risk of low blood sugar (hypoglycemia) in patients with type 2 diabetes, especially those who also take medications for type 2 diabetes such as sulfonylureas or insulin. This can be both a serious and common side effect. Talk to your healthcare provider about how to recognize and treat low blood sugar. Discuss checking your blood sugar before Patient starts and during Semaglutide/Tirzepatide/Retatrutide treatment.

○ Signs and symptoms of low blood sugar may include dizziness or light-headedness, blurred vision, anxiety, irritability, mood changes, sweating, slurred speech, hunger, confusion, drowsiness, shakiness, weakness, headache, fast heartbeat, or feeling jittery.

● Kidney disease(kidney failure). In people who have kidney problems, diarrhea, nausea, and vomiting may cause a loss of fluids (dehydration) which may cause kidney problems to become worse. It is important for Patient to drink fluids to help reduce the chance of dehydration.

● Serious allergic reactions. Stop using Semaglutide/Tirzepatide/Retatrutide and get medical help right away, if Patient has any symptoms of a serious allergic reaction, including swelling of Patient’s face, lips, tongue, or throat; problems breathing or swallowing; severe rash or itching; fainting or feeling dizzy; or very rapid heartbeat.

● Change in vision in patients with type 2 diabetes. Tell your healthcare provider if Patient has changes in vision during treatment with Semaglutide/Tirzepatide/Retatrutide.

● Increased heart rate. Semaglutide/Tirzepatide/Retatrutide can increase your heart rate while you are at rest. Tell your healthcare provider if Patient feels Patient’s heart racing or pounding in the chest and it lasts for several minutes.

● Depression or thoughts of suicide. You should pay attention to any mental changes, especially sudden changes in Patient’s mood, behaviors, thoughts, or feelings. Call your healthcare provider right away if Patient has any mental changes that are new, worse or worry you.

● Possible thyroid tumors, including cancer. Tell your healthcare provider if Patient gets a lump or swelling in Patient’s neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. In studies with rodents, Semaglutide/Tirzepatide/Retatrutide and medications that work like Semaglutide/Tirzepatide/Retatrutide caused thyroid tumors, including thyroid cancer. It is not known if Semaglutide/Tirzepatide/Retatrutide will cause thyroid tumors or a type of thyroid cancer called medullary thyroid carcinoma (MTC) in people.

Do not share Semaglutide/Tirzepatide/Retatrutide/B12 injections with other people, even if the needle has been changed. Sharing may give other people a serious infection or cause Patient to receive a serious infection from them.

Payment is expected at the time of treatment. The cost of the procedure is for materials and labor. There are no refunds.

I acknowledge that while good results are expected, I may be disappointed with the results of the procedure/treatments. I understand there is no guarantee of results from any treatment. Even though appropriate measures are taken to reduce side effects, they cannot be completely eliminated in every

case. I understand that the treatment may involve risks of complication or injury from both known and unknown causes. I agree to follow the pre- and post-treatment instructions carefully. I understand that compliance with the recommended pre- and post-procedure guidelines is crucial for healing and

reducing the risk of complications. I agree that any photographs and/or video images taken of me are usable for teaching or publication purposes unless I notify the Practice in writing that my photographs are not to be used. I understand that I will not be compensated from any party. Although photographs and/or video images will be used without identifying information, such as name, I understand it is possible someone may recognize me. I

further acknowledge that my participation is voluntary and agree that use of any photographs and/or video images confers no rights to me of ownership or royalties whatsoever. I agree that this constitutes full disclosure and that it supersedes any verbal or written disclosures. I understand that if the pictures

have already been published, that their use cannot be undone and that disclosures only apply for any future or new use.

I certify that I am a competent adult of at least 18 years of age. I understand that if I have questions or concerns regarding my treatment, I will notify my treatment provider immediately so that timely follow-up and intervention can be provided.

By signing this informed consent, I acknowledge that I have read this informed consent and certify I understand its contents in full. The nature, risks and purpose of the treatment have been explained to me, and all my questions have been answered to my satisfaction. I hereby give my voluntary consent to

treatment(s) described above with its associated risks. I hereby release the Practice and its successors, agents and assigns from liability associated with the treatment.