Slimspa Product Order Form

CALLA SLIMSPA SHOP

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SUPPLEMENTS & PRESCRIPTION MEDICATIONS

SUPPLEMENTS
Quantity
PRESCRIPTION MEDICATION FOR ACTIVE WEIGHT LOSS PATIENTS
(Please note that when entering quantity, 1 is equal to a 7 day supply of medication. Max delivery is 4 weeks of medications per order)

Quantity

B12 & LIPOTROPIC INJECTIONS (weekly shot)

Patients who actively participate in our weight loss program or our longterm maintentance program can receive up to 4 weeks of sterile prepared weekly injections including supplies to administer them. We must obtain a consent form that you have read the self-injection instructions and understand any possible associated risks.
Please do not order shots without consenting to the following form.
Would you like to read and sign the Informed Consent document? *

Informed Consent for Self Injection

I hereby acknowledge that this document is intended to serve as confirmation of informed consent for injections such as superficial or intramuscular injections by Dr. Suzanne Gil and/or associates/staff.

I have informed the physician of any known allergies to drugs or other substances, or of any past reactions to over the counter and prescription medications.  I have informed the doctor of all of my current medications and supplements.

I understand that:

  1. The injection process involves inserting a needle into various areas of the body.
  2. Risks of any and all of these injections include but are not limited to:
    1. Occasionally to commonly:
      1. Discomfort, ranging from mild to moderate pain, bruising, inflammation, injury and numbness at the site of the injection
      2. Dizziness or light-headed feeling after injections
    2. Extremely rare:
      1. Fainting or loss of consciousness during the injection process
      2. Allergic reaction to any or all of the components
      3. Infection at the injection site
  1. Although the vast majority of patients receiving these injections have noticeable improvement in energy level and improved ability to achieve weight loss, no guarantees have been made as to my individual outcome.
  2. I agree to call the staff at Calla Slimspa in a timely fashion if I have any concerns after an injection.
  3. I will not hold Calla Slimspa Medical Center, Dr Suzanne Gil or any of her staff liable for any complications arising from my decision to perform my own injections.
i, the undersigned, confirm that *
Signature *
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Quantity

Shakes & Bars (CURBSIDE ONLY)

SHAKES AND BARS
Quantity
 🛈

SHIPPING ADDRESS

SHIPPING AND HANDLING

Shipping  and Handling Options
Please note that all orders will be processed daily except for Saturday, Sunday, Monday and holidays. If shipping, you can expect delivery in 3 to 5 business days.
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