I hereby certify that the foregoing history is true and complete to the best of my knowledge and I have received and read the Semaglutide Information on website, have had an opportunity to ask questions that were answered to my satisfaction, and do wish to receive the Semaglutide shot fully understanding the risks and the benefits. I hereby consent to the administration of the Semaglutide. Furthermore, I hereby release and forever discharge for myself, my heirs, executors, administrators and assignees, KMM—Kaiser Medical Management and their employees, owners and representatives, contract workers and any/all health providers involved with providing this service, as well as the company sponsoring this clinic and their agents, representatives, employees, successors, assignees, governing bodies, and advisory committees from any and all claims, demands, actions and causes of action, which may result from participation in this program. *