Informed Consent for Medically Management Weight Loss Therapy BOTTUMZUP

I voluntarily consent to participate in the medically managed weight loss program provided by Bottumzup Health and Wellness, LLC. I understand that treatment may include nutrition and lifestyle recommendations, laboratory monitoring, prescription medications, and other treatments determined appropriate by my healthcare provider.

Please review and check each box to acknowledge your understanding and agreement.

Name

First NameLast Name

Date

Signature

Patient Responsibilities & Follow-Up. Please review and check each box to acknowledge your understanding and agreement.

Final Acknowledgment & Consent

Risks, Benefits & Alternatives Acknowledgment
I understand that medically managed weight loss has potential risks and benefits. Potential benefits of weight reduction may include improvement in overall health and quality of life and may reduce or improve certain obesity-related health risks and conditions.

I understand that individual results vary and that no specific amount of weight loss or health improvement is guaranteed.

I understand that medically managed weight loss is one of several approaches available to me. Alternatives may include:

Nutrition and lifestyle modification without medication.
Other FDA-approved weight-management medications, when appropriate.
Structured behavioral or commercial weight-management programs.
Referral to a dietitian or other specialist.
Bariatric/metabolic surgery when medically appropriate.
Choosing not to pursue weight-loss treatment at this time

Please review and check each box to acknowledge your understanding and agreement

By signing below, I voluntarily consent to participate in the medically managed weight loss program at Bottumzup Health and Wellness, LLC.

Signature

Date

Please review and check each box to acknowledge your understanding and agreement----GLP-1 / GIP Medication-Specific Risks

Thyroid C-Cell Tumor Warning: I understand that certain GLP-1–based medications, including semaglutide and Tirzepatide, carry a boxed warning regarding the risk of thyroid C-cell tumors observed in animal studies. It is not known whether these medications cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans. I understand that these medications are contraindicated if I have a personal or family history of MTC or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2), and I agree to disclose any such history to my provider.

Signature of Acknowledgement

Date

Weight Regain & Long-Term Management

I understand that obesity is a chronic condition and that weight regain may occur after weight loss, including after reducing or discontinuing weight-management medication. Maintaining weight loss may require ongoing lifestyle changes, medical follow-up, and, when clinically appropriate, continued treatment. I understand that individual results vary and long-term weight maintenance cannot be guaranteed.

INFORMED CONSENT FOR MEDICALLY MANAGED WEIGHT LOSS