Consent Form for Semaglutide Therapy
This document is intended to serve as a confirmation of informed consent for compounded Semaglutide, which is a prescription weight management medication.
Semaglutide is the first once-weekly medication in its class that’s FDA-approved to help with chronic weight management when used in combination with diet and exercise.
The largest clinical trial showed that people using Semaglutide lost an average of 14.9% of their initial body weight — 12.4% more than those who didn’t use the medication.
I voluntarily request that my medical provider treats my medical condition.
I have informed my provider of any known allergies, my medical conditions, medications, social/family history.
I have the right to be informed of any alternative options, side effects, and the risks and benefits.
I understand the mechanism of action of the medication. Semaglutide should be used with a reduced calorie meal plan and increased physical activity.
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.
I understand how it is to be administered.
I understand the prescription will come from a compounding pharmacy, which is FDA approved.
Prices may vary and change.
It has been explained to me that this medication could be harmful if taken inappropriately or without advice from the provider.
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
Acute kidney injury
Chronic renal failure exacerbation
I understand that if I become pregnant or start trying for pregnancy, I must stop this medication 2 months prior to trying to become pregnant. I am attesting that I am currently not pregnant and I am not breastfeeding.
I understand that if I have a diagnosis of DM 2, or taking any medications related to lowering my blood sugar levels, I will speak with my endocrinologist prior to starting Semaglutide therapy; specifically, if I am prescribed Insulin or any other GLP-1 agonist such as: Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy®, because the combination may increase my risk of hypoglycemia (low blood sugar) and dosage adjustments by my provider may be necessary. This is not an all-inclusive list.
I attest that I do not have personal or family history of Medullary thyroid cancer or MEN2 syndrome. I do not have history of pancreatitis
My provider can discuss my treatment plan with any co-treating pharmacist and/or healthcare providers.
I will always tell other providers about all medications I am taking.
I will take my medications only as prescribed according to the directions.
If I feel my medications are not effective, or are causing undesirable side effects, I will contact my provider for instructions.
I will not adjust my medications without prior instruction to do so.
I understand that the medication must be refrigerated.
I understand this medication must be self-injected in the subcutaneous tissue once weekly. I will not inject any less than 7 days unless directed by my medical provider.
I will not share needles and dispose of needles safely.
If I’m having troubles with the administration of the medication, I will seek help from my medical provider.
All refills will require an appointment.
I understand, I may need to schedule refill appointments ahead of time to avoid delays in refills.
I understand it is important to keep my medication away from children ( I am the only one who will use my medication. I will not give or sell my medication to anyone else.
If my Medical Provider deems it appropriate to start weaning my medication or transition to maintenance dosing, I will comply.
I understand that my medical provider may stop prescribing my medications if:
I am having unfavorable side effects or it’s not working to treat my medical condition
I have been untruthful in my medical or family history
I do not follow through with the recommended plan of care
I understand that the telehealth visits are not recorded. My healthcare provider will take notes as they normally would in the secure electronic medical records system, which is separate from the telehealth technology. If people are near me, private information may be overheard by others. You should be in a private place, so other people cannot hear you.
HIPAA Notice of Privacy Practices
At Sunshine Vitamins we understand that your health information is very personal. We are mandated by the Health Insurance Portability and Accountability Act (HIPAA) to protect your health information. Therefore, we create a record of the care and services you receive from us, which helps provide you with quality care and to comply with specific legal requirements. This Notice applies to all forms of your care generated by us and informs you about how we may use and disclose information about you. We also want to let you know that we also describe your rights to the health information we keep about you and our obligations regarding using and disclosing your health information.
We are required by law to:
* Make sure that health information that identifies you is kept private
* Give you this Notice of our legal duties and privacy practices concerning health information about you
*Follow the terms of the Notice that is currently in effect
How we may use and disclose health information about you:
*For appointment reminders
*As required by law
*As required by the Military or Veterans and Workers' Compensation
*Coroners, health examiners, and funeral directors
*National Security and Intelligence activities
*Protective Services for the President and others
*Public Health risks
*Health oversight activities
*Lawsuits and disputes
*To avert a serious threat to health and safety
*Security Officials for Inmates
Your rights regarding Health Information about you:
*Right to inspect and copy
*Right to Amend
*Right to Accounting of Disclosures
*Right to Request Restrictions
*Right to Request Confidential Communication
Your Medical Records: The original copy of your electronic medical record is the property of Sunshine Vitamins LLC. You may request a copy of your documents to be transferred by completing a medical records release form. We would like 14 business days from your request to prepare and send your records unless the records are urgent or for life-threatening health issues.
Changes to this Notice: We reserve the right to change this Notice. We will post a copy of the current notice in our facility with the current effective date.
Complaints: If you believe your privacy rights have been violated, you may file a complaint with us. So that you know, all complaints must be in writing. Please get in touch with the administrator where you were treated to file a complaint. For complete, detailed information regarding privacy laws, visit www.cms.gov/hipaa
Permission to Share your Health Information: We must follow specific federal guidelines and laws regarding the confidentiality of your personal health information. One prevents us from discussing anything in your medical file with anyone other than yourself or other medical personnel involved in your care. So, if you would like us to discuss lab results or additional personal information with your significant other, family members, or any other individuals, please let us know their names at your appointment.
I have read this form in its entirety. It has been explained to me. I have had the opportunity to ask questions and have all my questions answered. I fully understand the above information and have no further questions. By signing this form, I voluntarily give my consent for treatment and agree to the risks.