Weight Loss Consent

Weight Loss Medical History & Consent Form
Name

FirstnameLast name
Date of birth

DayMonthYear
Date
Phone

Area CodePhone Number
Mobile

Area CodePhone Number
Which weight loss program are you interested in?

Semaglutide (Wegovy)Tirzepatide (Mounjaro))Unsure
Gender

MaleFemale
Current Height*
Current Weight*
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact
Name
Phone

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Consent
Do you Consent to Weight Loss Program with Semaglutide/Tirzepatide Treatment?

YesNo
Patient signature

Clear
Date

DayMonthYear
What is your purpose for wanting to lose weight?
What is the reason you want to use Semaglutide or Tirzepatide specifically to lose weight?
How long has your weight been a problem?
Are you currently at your heaviest weight (if no, how much did you weight at your heaviest weight)?
What methods have you previously tried to lose weight?
Are you scared of needles/needle phobic/faint easily when you have blood taken?
Women only answer the following: Check those questions to which you answer yes leave the others blank

Are you trying for pregnancy or planning pregnancy in the near future?Are you or could you be pregnant?Are you breastfeeding?Are you on any type of hormone replacement therapy?Are you on any contraceptive methods?
Additional Comments
Patient Signature

Clear
List any prescription medications you are now taking:
List any self prescribed medications, dietary supplements, or vitamins you are now taking:
Date of last complete physical examination

DayMonthYear
List any other medical or diagnostic test you have had in the past two years
List hospitalisations, including dates of and reasons for hospitalisation (including surgeries)
List any drug or other causes of allergies including
Are you on any blood thinners?

YesNo
Weekly alcohol intake?
Do you or have you ever smoked?
Past or current medical history Check those questions to which you answer yes leave the others blank

Heart disease (such as heart attack, rheumatic fever, irregular heartbeat, angina, heart murmur)Diseases of the arteriesHigh blood cholesterolAnaemia or other blood disorders i.e. Sickle Cell disease, ThalassemiaStrokeMedullary thyroid cancerAny thyroid disease/problemsParathyroid problems or Adrenal gland problemsDiabetes or abnormal blood-sugar testsPhlebitis (inflammation of a vein)Deep vein thrombosis/blood clot in the leg (DVT) or PE (pulmonary embolism)Gallstones or any gallbladder disease (including jaundice)High blood pressureSevere refluxAny breathing problems (such as asthma, COPD, bronchitis)Infective endocarditisKidney problems including Chronic Kidney disease (CKD)Pancreas/digestion problems (including acute or chronic pancreatitis)Stomach/duodenum/gastric ulcerLiver problems (including hepatitis, liver failure, fatty liver, alcoholic liver disease)Any neurological problems (including Parkinson Disease)Severe stomach/gut problems (incl. Inflammatory bowel disease: Crohn's disease or Ulcerative colitis)Irritable bowel syndrome (IBS)Jaundice or gall bladder problemsSkin conditionsEating disorder (such as anorexia or bulimia)Mental health problems (including personality disorder, psychosis, diagnosis of depression)Self-diagnosis of depression, low mood, nervous or emotional problemsSubstance abuse (including alcohol or drugs)Any allergies (including food or drugs)
Do you have personal or family history of thyroid cancer?

YesNo
Do you have personal or family history of pancreatic cancer?

YesNo
Do you have personal or family history of pancreatitis?

YesNo
Do you have personal or family history of Diabetes?

YesNo
Comments
Patient Signature

Clear
Familial Diseases (Family history) Have you or your blood relatives had any of the following (include grandparents, aunts and uncles, but exclude cousins, relatives by marriage and half-relatives)?
Check those questions to which you answer yes leave the others blank

Heart attacks under age 50Strokes under age 50High blood pressureElevated cholesterolDiabetesAsthma or hay feverSkin allergiesCongenital heart disease (existing at birth but not hereditary)Heart operationsRed blood cell disorders i.e. Sickle Cell, Thalassaemia, AnaemiaGlaucomaKidney diseaseMedullary Thyroid CancerLeukaemia or cancer under age 60
Comments
Patient Signature

Clear
Consent to Semaglutide or Tirzepatide Treatment

Before you choose to use the services of practitioner: please read the following information FULLY AND CAREFULLY:
Why weight loss injections?
The main benefits may include:

1. These peptides are 94% similar to natural human GLP and therefore act as a physiological regulator of appetite and thereby reducing food intake by reducing feelings of hunger and increasing feelings of fullness/satiety.

2. Semaglutide and Tirzepatide are newly licensed medications indicated for the treatment of type-2 diabetes and now for the treatment of obesity.

3. For long term success, the treatment needs to be combined with lifestyle changes including nutritional, exercise, and behavioural change.

4. Weight loss can lead to secondary benefits by improving weight loss related health problems such as cardiovascular risk factors (including hypertension, blood glucose levels and waist circumference) and physical health-related Quality of Life.

I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent.

Since every human being is unique, we cannot guarantee any specific result from these treatments. Medication and or medical conditions may have a negative impact on the outcomes as well as lifestyle factors. Treatment should be discontinued after 12 weeks if the patient has not lost at least 5% of their initial body weight.

Patients need to follow the instructions carefully as provided separately in the patient instruction sheet. Patients must agree to notify their practitioner of any contraindications or side effects of the treatment.

It is essential to engage weekly with our medical staff throughout the treatment program.
HEALTH CONCERNS: If you suffer from a medical or pathological condition, you need to consult with an appropriate healthcare provider such as your General Practitioner. If you are under the care of another healthcare provider, it is important that you inform your other healthcare providers of your use of Semaglutide or Tirzepatide. If you are using medications of any kind, you are required to alert us of.

Note:If you have any physical or emotional reaction to Semaglutide treatment, discontinue use immediately, and contact your PRACTITIONER to ascertain if the reaction is adverse or an indication of the natural course of the body's adjustment to the treatment.

Laboratory testing may be done to any patient identified at risk to determine areas of dysfunction, not to diagnose or treat. Potential blood tests:
1. Full blood count
2. Liver function test
3. Kidney Function Tests
4. Cholesterol levels, HbA1c, Glucose
Patient groups who may require blood test monitoring at additional cost:
- Age 50 or above
- High blood pressure
- Pre-Diabetics
- Any significant medical problem
I confirm that I accept the extra blood tests with further monitoring as above if required with an additional cost as specified in the Patient price list.
Patient Name
Signature

Clear
COMMUNICATION: Every client is an individual, and it is not possible to determine in advance how your system will react to the treatment. It is sometimes necessary to adjust your program as we proceed. It is your responsibility to do your part by following healthy dietary guidelines, exercise your body and make necessary behavioural modifications.

1. Alternatives to Semaglutide and Tirzepatide therapy are surgical procedures, oral medical treatments (including Orlistat) and / or dietary and lifestyle changes alone. 2. Several weeks to months of treatment may be required depending on your individual response. 3. If a missed dose is more than 5 days late, the missed dose should not be taken, and the next dose should be taken at the normal time. 4. It is essential to combine eating, exercise and behavioural modifications. 5. Semaglutide and Tirzepatide should not be used in combination with another GLP-1 receptor agonist, insulin or insulin secretagogues (such as sulfonylureas) due to the risk of hypoglycemia. 6. Upon initiation of Semaglutide or Tirzepatide treatment in patients on warfarin or other coumarin derivatives more frequent monitoring of International Normalised Ratio (INR) is recommended. 7. Semaglutide and Tirzepatide cause a delay of gastric emptying and has the potential to impact the absorption of concomitantly administered oral medications. Monitor for potential consequences of delayed absorption of oral medications concomitantly administered.

8. There are several special warnings and precautions for use of Semaglutide and Tirzepatide including warnings on pancreatitis, cholelithiasis and cholecystitis, thyroid disease, heart rate, dehydration and hypoglycaemia in people with type 2 diabetes.

Thyroid adverse events, such as goitre have been reported in particular in patients with pre-existing thyroid disease. Semaglutide should therefore be used with caution in patients with thyroid disease.

A higher rate of cholelithiasis and cholecystitis (gallstone and gallbladder disease) has been observed in patients treated with Semaglutide and Tirzepatide. Cholelithiasis and cholecystitis may lead to hospitalisation and cholecystectomy (surgery to remove the gallbladder Patients should be aware of the characteristic symptoms of cholelithiasis and cholecystitis.

11. Signs and symptoms of dehydration, including renal impairment and acute renal failure, have been reported when using SEMAGLUTIDE and Tirzepatide. Patients should be advised of the potential risk of dehydration in relation to gastrointestinal side effects and take precautions to avoid fluid depletion. Patients should also be aware of the symptoms of increased heart rate.

Acute pancreatitis has been observed with the use of Semaglutide and Tiezepatide. Patients and their carers should be told how to recognise signs and symptoms of acute pancreatitis and advised to seek immediate medical attention if symptoms develop. If pancreatitis is suspected, semaglutide should be discontinued; if acute pancreatitis is confirmed, semaglutide should not be restarted.

13. Semaglutide and Tirzepatide may cause dose-dependent and Itreatment-duration-dependent thyroid C-cell tumours at clinically relevant exposures in both genders of rats and mice. It is unknown whether they cause thyroid C-cell tumours, including medullary thyroid carcinoma (cancer, MTC), in humans, as the human relevance of semaglutide-induced rodent thyroid C-cell tumours has not been determined. Patients should be aware of symptoms of thyroid tumours (such as a mass in the neck, difficulty swallowing, difficulty breathing or shortness of breath, persistent hoarseness
The most common Semaglutide and Tirzepatide side effects include:
- Nausea
- constipation
- decresed appetite
- dizziness
- hypoglycemia
- vomiting
- dyspepsia
- abdominal pain
- diarrhea
- headache
- fatigue
- increaded lipase
Nausea is the most common side effect when first starting, but decreases over time for most people as their body gets used to the medicine. The dosing schedule is designed to reduce the likelihood of gastrointestinal symptoms. Tell your health care professional if you have any side effect that bothers you or that does not go away.

Risks of of treatment include but are not limited to: a. Common or very common, reported in 5%: Dysgeusia (altered sense of taste), dry mouth, insomnia, asthenia; burping; constipation; diarrhoea; dizziness; dry mouth; gallbladder disorders; gastrointestinal discomfort; gastrointestinal disorders; insomnia; nausea; vomiting, hypoglycaemia, dyspepsia, gastritis, gastro-oesophageal reflux disease, flatulence, eructation, upper abdomen pain, abdomen distension, cholelithiasis, injection site reactions, fatigue, increased lipase and increased amylase.

b. Uncommon: Malaise; pancreatitis; tachycardia; urticaria

c.Rare: Renal impairment, allergic reaction, anaphylaxis
Do not take Semaglutide or Tirzepatide if any of the below contraindications apply to you:

a. Aged under 18 or above 75

b. Severe renal/kidney impairment (with eGFR of 15 or below) or a history of renal disease

c.Severe hepatic/liver impairment

d. Personal or family history of medullary thyroid cancer (MTC)

e.Hypersensitivity to Semaglutide or Tirzepatide or to any of the excipients: disodium phosphate dihydrate, propylene glycol, phenol and water for injection. f. Concurrent treatment with any other products for weight management

g. Weight problems related to endocrinological or eating disorders h. Concurrent insulin or sulfonylurea

i.Patients on warfarin (more frequent INR monitoring required) j.Concurrent use of any medicinal products with may cause weight gain k. Pregnancy, breastfeeding or trying to/planning to become pregnant. Congestive heart failure

m. History of pancreatitis, gallbladder disease, inflammatory bowel disease, diabetic gastroparesis.

n. Patients with a personal or family history of MEN 2 (Multiple Endocrine Neoplasia syndrome

The below drugs interact with Semaglutide and Tirzepatide and treatment should not be used concurrently. Drug interactions:
- Alogliptin
- Biphasic insulin aspart
- Biphasic insulin lispro
- Biphasic isophane insulin
- Canagliflozin
- Dapagliflozin
- Dulaglutide
- Empagliflozin
- Exenatide
- Glibenclamide
- Gliclazide
- Glimepiride
- Glipizide
- Any insulin including aspart, degludec, detemir, glargine, glulisine, lispro, isophane, zinc suspension
- Nateglinide
- Pioglitazone
- Repaglinide Saxagliptin, Sitagliptin, Vildagliptin
- Tolbutamide
I am aware that other unforeseeable complications could occur. I do not expect the clinic to anticipate and or explain all risk and possible complications. I rely on them to exercise judgment during the course of treatment. I understand the risks and benefits of the treatment and have had the opportunity to have all of my questions answered.
Patient Name
Signature

Clear
I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. At any stage during the treatment, I have the right to request that the procedure is terminated, however l accept that l will not be reimbursed once supply has commenced.

I am clear about the risks of using the medicationI am clear about the expected weight loss outcomes of this programI am clear about the diet, exercise and behavioral changes I need to make
My signature on this form affirms that I have given my consent to the Semaglutide protocol as specified above.
Patient Name
Signature

Clear
Date

DayMonthYear
Should be Empty:

Emergency Contact

Consent

Consent to Semaglutide or Tirzepatide Treatment

Why weight loss injections?