Semaglutide Consent Form

Semaglutide Consent Form

Patient Consent & Acknowledgment

Please review the Semaglutide Consent Form below. You may download, print, and sign the form, or complete it during your visit.

Questions About This Form?

If you have any questions about the Semaglutide Consent Form, please contact our office:

Phone: 202-737-6800

Fax: 202-737-4984

Website: www.yolandaholmesmd.com

Office: 1737 20th St. NW, Washington, DC 20009

Ready to Get Started?

Schedule a consultation with Dr. Yolanda C. Holmes to discuss whether Semaglutide treatment is right for you.

Schedule an Appointment

Or call 202-737-6800

How much weight do you want to lose?
How would you describe your ideal lifestyle?
What’s your primary goal with weight loss?
What are you most excited to do once you reach your goal?
What part of your life will benefit most from this transformation?
Have you used GLP-1 medications like Ozempic®️, Zepbound®️ or Wegovy®️ before?
Do you have any of the following conditions?
Ideal Weight
What’s your preferred time for us to call you & answer all your questions?
Contact Information: