Semaglutide & Tirzepatide Consent Form

Semaglutide & Tirzepatide Consent Form
Name*

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Date of Birth*
Phone Number*
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Date*

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How did you find out about us? Were you referred by someone, if so, who? Or did you see us on google/advertisement?
Medical Information
How tall are you?*
How much do you weigh?*
Please list any drug allergies you have.*
Please list all medications you take including supplements.*
Please list all chronic medical conditions.*
Do you have any history of renal or kidney problems?*
Do you have any history of Type 1 Diabetes or require insulin?*
Do you have any history of Gastroparesis, Thyroid Medullary Cancer or MEN Syndrome?*
Have you ever had Pancreatitis or Gallstones?*
Currently pregnant or plan to become pregnant in the next year?Currently Breastfeeding?Currently being treated for cancer?Active or history of eating disorder?Active gallbladder disease?Active substance abuse or dependency?Type 1 Diabetes?Bariatric Surgery (within the past 18 months)?Pancreatitis within the past 6 months or history of pancreatitis caused by taking a GLP-1 medication?History of medullary thyroid cancer/MEN syndrome?Family History of medullary thyroid cancer/MEN syndrome?GastroparesisNONE OF THESE APPLY TO ME
Consent

I request and consent to injections of Semaglutide/Tirzepatide and strict dietary restrictions for the purpose of losing weight. I fully understand this will be administered and monitored by the medical providers at Fitzcare Associates, LLC. I understand that as part of the program I will be given a limited physical and orientation to the program, will be instructed on how to administer the injections myself or make arrangements to have someone do so. I understand that initial blood tests may be performed to rule out any conditions that would disqualify me from the program or require any prior treatment before starting the program. I agree to immediately report any problems that might occur to the medical provider during the treatment program. I further understand that there could be risks involved as there are with all medications and that not complying with the dosage recommendations and dietary restrictions could increase risks and alter the results. Product information is available upon request. I agree that I am, and will be under the care of another medical provider for all other conditions. Fitzcare Associates, LLC works in conjunction with, but cannot replace, regular primary care physicians, such as general practitioners or other specialists in Family Medicine or Internal Medicine. Because we are committed to enabling our patients to obtain and maintain health and wellness naturally, and the services provided by our office are based upon a natural and preventative approach, it is rare that this program is covered by insurance companies. Weight loss, in general, is rarely covered by insurance companies. For this reason, we do not accept or bill insurance for this program. Once labs are done, the physical is performed, and the treatment is started, we cannot honor any refund requests based on scheduling conflicts, missed doses, unsatisfactory results, etc. If blood work is indicated, the test will be conducted by a licensed lab and the fee added to your initial visit fee. I have read and understand all of the above and have been informed of potential side effects and risks that may be associated with Semaglutide injections. I fully understand what I am signing and hereby request and consent to weight-loss treatment using injections of Semaglutide. I have disclosed my full medical history and have been physically examined by my health care practitioner. I am aware the common risks, benefits, side effects and adverse reactions of Semaglutide and I have had full opportunity to ask any questions. I understand that results may vary and once I have begun the protocol, I am committed to seeing it through.
Potential Risks & Side Effects

There are several special warnings and precautions for use of Semaglutide/Tirzepatide including warnings on pancreatitis, cholelithiasis and cholecystitis, thyroid disease, heart rate, dehydration and hypoglycemia in people with type 2 diabetes.Thyroid adverse events, such as goiter have been reported in particular in patients with pre-existing thyroid disease. Semaglutide/Tirzepatide 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/Tirzepatide. 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.Signs and symptoms of dehydration, including renal impairment and acute renal failure, have been reported in patients treated with Semaglutide/Tirzepatide. Patients treated with Semaglutide/Tirzepatide 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/Tirzepatide. If pancreatitis is suspected, Semaglutide/Tirzepatide should be discontinued; if acute pancreatitis is confirmed, Semaglutide/Tirzepatide should not be restarted.Semaglutide/Tirzepatide may cause thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Semaglutide/Tirzepatide causes thyroid C-cell tumors, including medullary thyroid carcinoma (cancer, MTC), in humans, as the human relevance of Semaglutide/Tirzepatide -induced rodent thyroid C-cell tumors has not been determined. Patients should be aware of symptoms of thyroid tumors (such as a mass in the neck, difficulty swallowing, difficulty breathing or shortness of breath, persistent hoarseness. Patient should also be advised of the risk of gastroparesis (stomach paralysis) due to delayed gastric emptying. The most common Semaglutide/Tirzepatide side effects are:· Nausea· Constipation· Decresed appetite· Dizziness· Hypoglycemia· Vomiting· Dyspepsia· Abdominal pain· Diarrhea· Headache· Fatigue· Increased lipaseNausea is the most common side effect when first starting Semaglutide/Tirzepatide 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/Tirzepatide 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, gastroesophageal reflux disease, flatulence, eructation, upper abdomen pain, abdomen distension, cholelithiasis, injection site reactions, fatigue, increased lipase and increased amylase.Uncommon: Malaise; pancreatitis; tachycardia; urticariaRare: Renal impairment, allergic reaction, anaphylaxis
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

No Refund / No Return Policy
I acknowledge that prescription medications cannot be returned or refunded once dispensed by the pharmacy, in accordance with FDA and pharmacy regulations. By completing my order, I accept financial responsibility for the prescription medication. I understand that disputes or chargebacks submitted after medication processing do not invalidate this policy.
I have read and understand the above statement. I acknowledge the risks and potential side effects by taking medication prescribed to me.
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Semaglutide & Tirzepatide Consent Form

Medical Information

Consent

Potential Risks & Side Effects