Weight Management (semaglutide) Prescription Drug Management Consent
This document is intended to serve as a confirmation of informed consent for compounded semaglutide, which is a prescription weight management medication.
A. Patient Informed Consent 1. I voluntarily request that Travicia Garrett FNP-C (provider) treats my medical condition. 2. I have informed my provider of any known allergies, my medical conditions, medications, social/family history. 3. I have the right to be informed of any alternative options, side effects, and the risks and benefits. 4. I understand the mechanism of action of the medication. 5. I understand how it is to be administered. 6. I understand the prescription will come from a compounding pharmacy, which is not FDA approved. I have been told that the manufacturing facility itself is FDA monitored along with third party testing on the medication itself. 7.Prices may vary and change. My charge will include my time with Travicia Garrett (Televisit and supplies, and medication 8. Travicia Garrett may change the pharmacy based on several factors (availability, shipping time, cost Travicia Garrett will tell you as this happens. 9.It has been explained to me that this medication could be harmful if taken inappropriately or without advice from the provider. 10. I understand this medication may cause adverse side effects (see below I understand this list is not complete and it describes the most common side effects, and that death is also a possibility of taking this medication. I understand symptoms may be worse after there has been a change in my medication dose or when first starting the medication. Common side effects include, but are not limited to:
Gastrointestinal: Nausea/vomiting, abdominal pain, Diarrhea/constipation, dyspepsia, abdominal distension, eructation, flatulence, gastroenteritis, GERD, gastritis, lipase increase, amylase increase Neurological: Headache, dizziness Cardiac: Heart rate increase, Hypotension Endocrine: Fatigue, hypoglycemia (diabetic patients), alopecia Ophthalmic: Retinal disorder (diabetic patients) Skin: redness or pain at injection site
Serious Reactions include, but are not limited to: Thyroid C-cell tumor (animal studies) Medullary thyroid cancer Hypersensitivity reaction Anaphylaxis Angioedema Acute kidney injury Chronic renal failure exacerbation
Cholecystitis Syncope B. I understand that I have the following responsibilities: