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HOME
- Monthly Specials
ABOUT US
TREATMENTS
- SURGICAL
  - LIPO SCULPTING
  - EYELID RENU
- MEDICAL AESTHETICS
  - BOTOX
  - DERMAL FILLERS
  - SCULPTRA
  - THREAD LIFTS
  - IV INFUSIONS
  - PRP
  - PRF
AESTHETIC BEAUTY
SHOP
PRICE LIST

Weight Management Patient History Questionnaire 3/3

Legal Consents & Signatures 3/3

Date

ID Number

Title

Name

Surname

Gender

Date of Birth

Age

Marital Status

City

Province

New Field:

Cell

Emergency contact

Relation to Patient

Primary Care Physician

Contact Details

I authorise the release of any medical information to any physicians involved in my care

Yes

No

The staff at Asteria Aesthetics will provide the tools you need to achieve the weight loss goal that YOU set to yourself. We will offer the best advice that we can give and add some little “tricks’’ that we have either learned from personal experience or from the many clients who have shared their helpful hints with us.

The program is made up of the following: The client’s desire to lose weight, improve their health and the willingness to make the necessary lifestyle changes to achieve their goal and maintain that goal.

The staff will share some little tricks to help you learn from day one how to keep the weight off. We do not believe that clients “cheat”, we call it “living”. It is not necessary to feel like you have lost all progress if you have a big party to go to or some bad days which ended up with some comfort foods. Those days will happen and as long as it is not day after day, it is easy to “offset” those days. We will teach you what to do while you are in the “dieting phase” so that once you reach your goal you will have already practiced and become comfortable with the remedies to help you maintain your desired weight.

We would much appreciate having Before and After pictures of you to share in our marketing efforts. If you are not comfortable with this please write “NO” at the end of this paragraph. It is not a requirement. If you are so inclined, we would appreciate sharing your personal progress on Facebook, Instagram, and other relevant social media sites.

To justify the use of weight loss enhancers, the patient must have a Body Mass Index (BMI) of 30 or above, or a BMI greater than 26 with at least one comorbidity factor, or a measurable body fat content equal to or greater than 25% of total body weight for male patients or 30% of total body weight for women.

Please check if you have any of the following:

Cardiovascular Disease

Chronic Lung Disease

Myocardial Infarction (MI)

Emphysema

Hypertension (HBP)

History of Pancreatitis

Pregnancy

History of Gallstones

Chronic Obstructive Pulmonary Disease

History of MTC (Personal and Family)

Client Signature

Date

Doctors Signature

Date

Consent

I understand that I will be meeting with a member of the medical staff to review all the literature associated with the program and I will be given the opportunity to have all of my questions regarding the weight loss program answered. All of the information that I have provided to the medical staff is correct and complete to the best of my knowledge. I understand that medications used in this program may cause or aggravate high blood pressure or alter insulin require-ments in diabetes and that both hypertension and diabetes may improve with weight loss. I understand that although unusual, there may be adverse reactions to the medications used including rapid heart rate, restlessness, agitations, poor sleeping, dizziness, headaches, blurred vision, psychotic states, dryness of the mouth, constipation, diarrhea, nau-sea, stomach pains, urinary frequency/discomfort, and changes in sex drive. I understand that dietary management and physical exercise are a necessary component of this, and all weight loss programs MUST be utilized for optimum results. I have not been given any guarantees or promises regarding the expectations or results in this weight loss program. I freely and voluntarily consent to participate and agree to follow the instructions given. I will not change dosages or frequency of any medications prescribed. Please be advised using any recreational drugs; ie: cocaine, marijuana, or heroin will cause FATAL adverse reactions with any medication prescription.

Consent

I give my permission for the staff to review this program with me and guide me in my weight loss journey.

Clients Name

Client Signature

Date

Witness Signature

Date

Consent

Semaglutide is a GLP 1 Antagonist. It mimics the action of a hormone called Glucagon-Like Peptide (GLP). Glucagon is the storage form of carbohydrates, which is a factor in weight gain. Glucagon causes stored carbohydrates to break down and move into the bloodstream for metabolism. Glucagon decreases carbohydrate absorption from the gut while decreasing appetite by slowing gastric mobility. When blood sugar rises after eating, these drugs stimulate the body to produce more insulin. The extra insulin helps lower blood sugar. The lower blood sugar levels help control type 2 Diabetes. Tirzepatide affects two receptors (dual action), acting on both GIP (glucose insulinotropic polypeptide) and GLP-1 receptors (glucagon-like peptide). This dual response further increases safety and decreases hunger. Combined with a sensible diet and healthy lifestyle changes, Semaglutide and Tirzepatide effectively reduce body weight. Semaglutide and Tirzepatide curb appetite and slow food movement from the stomach to the small intestines. As a result, clients feel full longer and subsequently eat less, leading to weight loss. Further studies have demonstrated that GLP-1 and SGLT-2 (sodium-glucose transport protein 2) inhibitors may reduce the risk of heart disease, heart failure, stroke, and kidney disease. Many clients prescribed these medications have seen blood pressure and cholesterol levels improve.

Side Effects: List can be found below this form.

Medications: Do you take any of the following medications? Please check if currently prescribed:

Amaryl

Glimepiride

Glucotrol

Glipizide

Glipizide ER

Glynase

Tolbutamide

Tolazamide

Effects on Birth Control and Pregnancy GLP-1 medications may affect the efficacy of oral contraceptives and birth control shots. Clients using oral birth control medications and birth control shots are strongly encouraged to use an alternative birth control plan while enrolled in GLP-1 Weight Loss Programs. Pregnancy Clients who are pregnant or attempting to become pregnant should stop using these medications. Animal studies have shown that these agonists may reduce embryo size and may cause developmental abnormalities. Anesthesia Clients scheduling any surgical procedure involving anesthesia must stop using GLP-1 medications at least two weeks before the procedure. Clients should notify anesthesiologists that they have been prescribed GLP-1 medications.

Exclusions from GLP-1 Weight Loss Programs Clients diagnosed with one or more of the following conditions may not participate in GLP-1 Weight Loss Programs. Please review this list carefully and check any pre-existing conditions.

Medullary Thyroid Cancer

Multiple Endocrine Neoplasia(All types or tumors)

Pancreatitis

Hepatobiliary disease (GB disease)

Gastroparesis

Abnormal liver function tests

Please initial here if, to the best of your knowledge, you are free of all the above medical conditions.

Following a thorough review of your health assessment, our Medical Doctors will make the final determination for full participation in the GLP-1 Weight Program.

Thank you for contacting us.
We will get back to you as soon as possible.

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Side Effects:

Abdominal pain (most common) - Redness
Constipation
Dizziness
Nausea
Blurred vision
Headache
GERD
Depression; confusion; mood changes
Gall Bladder pain with pre-existing cholelithiasis or gallstones Irritability
Hair Loss
Complications with anesthesia
Belching
Diarrhea
Vomiting
Injection site reactions

Hypoglycemia (low blood sugar) has been linked to GLP-1 medications when combined with insulin or sulfonylureas.

Any severe abdominal pain, vomiting, or constipation should be reported to the Asteria Aesthetics staff for referral to our Medical Director for guidance.

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- Monthly Specials
ABOUT US
TREATMENTS
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  - LIPO SCULPTING
  - EYELID RENU
- MEDICAL AESTHETICS
  - BOTOX
  - DERMAL FILLERS
  - SCULPTRA
  - THREAD LIFTS
  - IV INFUSIONS
  - PRP
  - PRF
AESTHETIC BEAUTY
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Contact

Asteria Group

17 Midas Avenue, Olympus Boulevard Office Park, Heartsease Building, First Floor, Asteria House.

Reception: 012 998 4486

WhatsApp: 074 745 9104 / 061 724 5034
Emergency After Hours Only (no bookings):

084 767 5954 / 061 724 5034

Email: admin@asteriasa.co.za

Clinic Hours

Mon - Fri: 8:00 am - 5:30 pm
Saturday: 8:00 am - 1:00 pm
Sunday: Closed

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