Semaglutide/Tirzepatide Consent Form

Semaglutide and Tirzepatide are human-based glucagon-like peptide-1 receptor agonist prescribed as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) that is considered outside a healthy range.

While using Semaglutide/Tirzepatide, it is highly recommended that you:

·         Eat a fibrous diet. Focus on fruits and vegetables that are high in fiber.

·         Eat small high-protein meals as digestion is slowed down while on this medication.

·         Avoid foods high in fat as they take longer to digest.

·         Limit alcohol intake as this medication can lower blood pressure.

·         Drink at least 32oz of water a day to avoid constipation.

 

Do NOT take this medication if:

·         You have a personal or family history of medullary thyroid carcinoma (Thyroid Cancer)

·         Multiple Endocrine Neoplasia syndrome type 2

·         You are pregnant or plan to become pregnant while taking this medicine.

·         You are diabetic and/or taking any medications related to lowering your blood sugar levels without speaking with your endocrinologist.

·         Specifically, if you are prescribed Insulin because the combination may increase your risk of hypoglycemia (low blood sugar) and dosage adjustments by your provider may be necessary.

·         You have a history of Pancreatitis.

·         You are allergic to Semaglutide or any other GLP-1 agonist such as: Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy®;Mounjaro®, Zepbound™

·         If you have other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details. Before using this medication, tell your doctor your medical history.

Possible drug interactions:

Anti-diabetic agents, specifically: Insulin and Sulfonylureas (e.g., glyburide, glipizide, glimepiride, tolbutamide) due to the increased risk of hypoglycemia (low blood sugar). Do not take with other GLP-1 agonist medicines such as: Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy® Mounjaro®, Zepbound™(THIS IS NOT AN ALL-INCLUSIVE LIST). Other medications used in diabetes, please tell your provider about any medications that may lower your blood sugar.

Possible side effects

 Nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dyspepsia, dizziness, abdominal distension, belching, hypoglycemia, flatulence, gastroenteritis, and gastroesophageal reflux disease.

Subcutaneous Injections

 Common injection site reactions are characterized by itching and burning at the site of administration with or without thickening of the skin(welting). If you notice other side effects not listed above, contact your doctor.

A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, or trouble breathing. Report adverse side effects to your doctor or pharmacist. In the event of any emergency, call 911 immediately.

IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THIS TREATMENT, OR ANY QUESTIONS WHATSOEVER CONCERNING THIS PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK THE STAFF NOW BEFORE SIGNING THIS CONSENT FORM.

By signing, I certify that I have read and understand the contents of this form. I am aware of the possible side effects and drug interactions and give my consent for treatment. I have informed the medical staff of any known allergies to drugs or other substances, and any past adverse reactions I’ve experienced. I have informed the medical staff of all medications and supplements I’m currently taking. I understand there are other ways and programs that can assist me in my desire to decrease my body weight and acknowledge that no guarantees have been made to me concerning my results.

Semaglutide/Tirzepatide Injection Instructions:

1.    You will only take the shot one time per week. Pick a day that you will remember to take it, not to get off schedule. Take 30 minutes before or after any other medications or vitamins.

2.   You will receive 1 vial that will last 1-2 months (dose/patient-specific). Due to pharmacy delays it may take up to 2 weeks to receive your next vial, please order accordingly.

3.   Pinch fat in your belly/abdominal area or other as shown below (see image), clean it with alcohol, and give yourself an injection.

4.   Do not use the same site for each injection.

5·   If you choose to inject in the same area, always use a different spot in that area.

6.    Keep away from heat and out of the light.

7.    The vial will break if dropped.

8.    If you miss a dose, take the missed dose as soon as possible within 5 days after the missed dose.

9.    Keep Semaglutide and all medicines out of the reach of children.

10.   Your dose will increase weekly if tolerated.

11.   If you do not tolerate the dose, please let us know.

12.   Do not reuse your needles. Use a clean syringe daily. Dispose of your needles properly by using a hard plastic container such as a milk jug or 2-liter bottle to place your needles in for disposal.