By signing and submitting this form, you agree that you have answered all questions truthfully and to the best of your ability, and you are requesting a prescription for Semaglutide. A basic evaluation will be administered at the time of your appointment. If you feel that you are not healthy enough to receive this medication or do not meet the requirements, do not submit this form. Human-based glucagon-like peptide-1 receptor antagonists (GLP-1 RA) such as Semaglutide (compounded) Are prescribed as an adjunct to A reduced calorie diet and increased physical activity for chronic weight management in adults with initial body mass index that is considered outside a healthy range.
While using a GLP-1 RA it is HIGHLY RECOMMENDED THAT YOU: - Eat a fibrous diet. focus on fruits and vegetables that are higher in fiber. - Eat small high protein meals as digestion is slowed down while on this
- Avoid foods high in fat as they take longer to digest
- Drink at least 32 OZ of water a day to avoid constipation
DO NOT TAKE THIS MEDICATION IF:
You have a personal or family history of medullary thyroid carcinoma. You have a personal history of multiple endocrine neoplasia syndrome type 2. You are pregnant or plan to become pregnant while taking this medication. You are diabetic and or taking any medications related to lowering blood sugar levels without speaking with your endocrinologist or Primary Care provider. 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 are allergic to Semaglutide or any other GLP-1 antagonist.
This is not an all-inclusive list.
Anti-diabetic agents, specifically insulin and sulfonylureas due to the increased risk of hypoglycemia. do not take with other GLP-1 antagonist medicines Blood pressure medications: as weight loss may occur on this medication, it is imperative to monitor your blood pressure at home while on this medication and taking blood pressure medication at the same time. Weight loss may naturally decrease your blood pressure which may make it necessary to adjust your blood pressure medication dosage. As weight loss occurs, it is recommended to keep a blood pressure diary.
SIDE EFFECTS:
Nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dyspepsia, dizziness, abdominal distension, belching, hypoglycemia, flatulence, gastroenteritis, and gastroesophageal reflux disease. Possible side effects of subcutaneous injections: itching, burning at the side of administration with or without thickening of the skin.
If you notice other side effects not listed above, contact your Healthcare provider. 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 or swelling, especially of the face, tongue or throat, severe dizziness, trouble breathing.
GLP-1 RA may cause other serious issues such as possible thyroid tumors, including cancer. Tell your healthcare provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. In studies with rodents, Semaglutide causes thyroid tumors, including thyroid cancer. It is not known if Semaglutide GLP-1 RA will cause thyroid tumors, or a type of thyroid cancer called medullary thyroid carcinoma in people.
Report adverse side effects to your clinician. In the event of any emergency, call 911 immediately.
Every 30 days you must request a refill and report to your clinician the following information: Current weight, blood pressure, concerns regarding treatment, change in other prescribed medications, change in medical history, change and desired weight loss outcome. The most efficient method to request a refill is to contact your clinician via text. It can take 7 to 10 business days to receive some forms of Semaglutide. Please be mindful of reporting to your clinician in a timely manner to not delay your
In the event of an emergency, call 911 immediately
If you have any questions as to the risks or hazards of the treatment, or any questions concerning this proposed treatment or other possible treatments, ask 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 reaction I've experienced. I have
informed the medical staff of all medications and supplements I'm currently taking. I understand that there are ways in 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.
RELEASE FROM MEDICAL LIABILITY AND MALPRACTICE CLAIMS:
I agree to release Dr. Brian Crenshaw and all his associates from all medical liability and malpractice claims related to any and all care.
This consent covers the initial and all future prescriptions for this medication.
I understand that this is a prescription therapy and is not eligible for a refund.
I have read and agree to the above. my questions have been answered and I understand the treatment and goals. I understand and accept the potential risks associated with GLP-1ra therapy as stated above and consent to treatment.
I have read all of the above information and if I have questions I will ask the clinician.
I certify that I have been informed of the risks and benefits of off-label treatment.
I will review the side effects of all medications I am prescribed and immediately inform the doctor of any side effects.
BY SIGNING BELOW, I INDICATE THAT I'VE READ AND UNDERSTAND ALL THE INFORMATION ABOVE AND WILL ASK QUESTIONS ON ANY AND ALL INFORMATION I DO NOT UNDERSTAND.