I understand this program uses an injectable peptide medication, that Dr. Sahafi decides on treatment after reviewing this screening, and that submitting it does not guarantee treatment.

I understand possible side effects include nausea, vomiting, diarrhea, and constipation, and less often pancreatitis, gallbladder problems, dehydration with kidney injury, and low blood sugar when used with diabetes medicines. Some medicines in this class carry a boxed warning about thyroid C-cell tumors seen in animal studies.

I will contact the office right away for severe stomach pain, vomiting that will not stop, a lump or swelling in my neck, trouble swallowing, vision changes, or signs of an allergic reaction. In an emergency I will call 911.

I understand the medication is meant to be used with healthy eating and physical activity, and that results vary from person to person.

My answers are true and complete to the best of my knowledge. I will tell the office if my health or medications change.