I hereby certify that the foregoing history is true and complete to the best of my knowledge and I have received and read the Saxenda information KMM's website online, have had an opportunity to ask questions that were answered to my satisfaction, and do wish to receive the Saxenda shot fully understanding the risks and the benefits. I hereby consent to the administration of the Saxenda. 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. I will not seek to be reimbursed by Medicare, Medicaid, Tricare or any other insurer/payer for this shot program and understand it is an out-of-pocket expense that I am 100% responsible for. Your personal information and results shall be held strictly confidential. I understand KMM-Kaiser Medical Management is not a Medicare participating provider. Insurance/Medicare will not be billed. For all safety reasons, KMM holds the right to refuse service with or without explanation. My submission on this site is my understanding, compliance, consent, and agreement to receiving Saxenda shot. I understand if on the Discount Program KMM will take pictures of front/back/side from the neck down showing my midsection. No face or names will be used. KMM holds the right to photos.*