Ozempic Consent Form – FaceTherapy NI

- Consultation Date & Time
- Date of Birth
- First Name
- Last Name
- Gender
  - Male
  - Female
- Occupation
- Phone
- Mobile
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact
- Name
- Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

GP/Consultant
- Name
- Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Permissong
I give/do not give my permission to inform my GP about the Ozempic treatment that I am about to receive (please circle).
- Yes
- No
- Patient signature
- Date

Medical Questions
What is your purpose for having Ozempic treatment?
What is the reason you want to lose weight?
How long has your weight been a problem?
Are you currently at your heaviest weight (if no, how much did you weight at your heaviest weight)?
What methods have you previously tried to lose weight?
Are you scared of needles/needle phobic/faint easily when you have blood taken?
Women only answer the following:
Check those questions to which you answer yes (leave the others blank).
- re you trying for pregnancy or planning pregnancy in the near future?
- Are you or could you be pregnant?
- Are you breastfeeding?
- Are you on any type of hormone replacement therapy?
- Are you on any contraceptive methods?
Comments
Patient Signature

Emergency Contact