Semaglutide/Tirzepatide

Semaglutide/Cagrilintide/Tirzepatide/Retatrutide Consent Form
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I give/do not give my permission to inform my PCP about the GLP-1 treatment that I am about to receive
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What is your purpose for having Semaglutide treatment?*
What is the reason you want 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?
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List any prescription medications you are now taking*
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List any other medical or diagnostic test you have had in the past two years*
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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 pressure(Hypertension) Severe 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 any of the discussed contraindications apply to you (refer to last page)NoneOther
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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)?
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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 diseaseObesity (20 or more pounds overweight)Leukaemia or cancer under age 60None
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Before you choose to use the services of practitioner: please read the following information
Consent to Semaglutide/Cagrilintide/Tirzepatide/Retatrutide Treatment

Before you choose to use the services of practitioner: please read the following information FULLY AND CAREFULLY:
Why Semaglutide/Cagrilintide/Tirzepatide/Retatrutide injections?
My signature on this form affirms that I have given my consent to the Semaglutide/Cagrilintide/Tirzepatide/Retatrutide protocol as discussed with the practitioner.
HEALTH CONCERNS: If you suffer from a medical or pathological condition, you need to consult with an appropriate healthcare provider such as your GP or Consultant. 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. If you are using medications of any kind, you are required to alert us of.

Note:If you have any physicalor emotional reaction to GLP-1/GIP 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.
I opt out of laboratory testing*
I need prior laboratory testing*
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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/Cagrilintide/Tirzepatide/Retatrutide 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 with Semaglutide.

5. Semaglutide/Cagrilintide/Tirzepatide/Retatrutide should not be used in combination with another GLP-1 receptor agonist, insulin or insulin secretagogues (such as sulfonylureas) due to the risk of hypoglycaemia.

6. Upon initiation of Semaglutide/Cagrilintide/Tirzepatide/Retatrutide treatment in patients on warfarin or other coumarin derivatives more frequent monitoring of International Normalised Ratio (INR) is recommended.

7. Semaglutide/Cagrilintide/Tirzepatide/Retatrutide causes 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 with Semaglutide

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

9. Thyroid adverse events, such as goiter have been reported in particular in patients with pre-existing thyroid disease. Semaglutide/Cagrilintide/Tirzepatide/Retatrutide should therefore be used with caution in patients with thyroid disease.

10. A higher rate of cholelithiasis and cholecystitis (gallstone and gallbladder disease) has been observed in patients treated with semaglutide. Cholelithiasis and cholecystitis may lead to hospitalization 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 in patients treated with Semaglutide/Cagrilintide/Tirzepatide/Retatrutide. Patients treated with semaglutide 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.

12. Acute pancreatitis has been observed with the use of Semaglutide/Cagrilintide/Tirzepatide/Retatrutide. Patients and their carers should be told how to recognize 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/Cagrilintide/Tirzepatide/Retatrutide may cause dose-dependent and I treatment-duration-dependent thyroid C-cell tumours at clinically relevant exposures in both genders of rats and mice. It is unknown whether Semaglutide/Cagrilintide/Tirzepatide/Retatrutide causes thyroid C-cell tumours, including medullary thyroid carcinoma (cancer, MTC), in humans, as the human relevance of semaglutide/tirzepatide-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 side effects are:
- 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 Semaglutide/Cagrilintide/Tirzepatide/Retatrutide 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 Semaglutide/Cagrilintide/Tirzepatide/Retatrutide treatment include but not limited to:

a. Common or very common, reported in 5%: Dysgeusia (altered sense of taste), dry mouth, insomnia, asthenia; burping; constipation; diarrhea; dizziness; dry mouth; gallbladder disorders; gastrointestinal discomfort; gastrointestinal disorders; insomnia; nausea; vomiting, hypoglycemia, 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
Signature*

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My signature on this form affirms that I have given my consent to the Semaglutide/Cagrilintide/Tirzepatide/Retatrutide protocol as specified below:
Patient Name*
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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 behavioural changes I need to make
My signature on this form affirms that I have given my consent to the Semaglutide/Cagrilintide/Tirzepatide/Retatrutide protocol as discussed with the practitioner.
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