Semaglutide and/or Tirzepatide Weight Loss Prescription Drug Management Consent:
Southtowns Colon Hydrotherapy/Essential IV Therapy of OP 6576 East Quaker Street, Suite 1 Orchard Park, NY 14127
716-982-4703 or 716-982-5098
This document is intended to serve as a confirmation of informed consent for compounded semaglutide and/or tirzepatide, which is a prescription weight management medication.
A. Patient Informed Consent
1. I voluntarily request that Juliann Lazzaro, APRN (provider) and the staff of Southtowns Colon Hydrotherapy, LLC, help me manage my weight loss needs, via semaglutide and/or tirzepatide and supporting vitamin treatments.
2. I have informed my provider of any known allergies, my medical conditions, medications, social/family history.
3.I have the right to be informed of any alternative options, side effects, and the risks and benefits.
4. I understand the mechanism of action of the medication.
5. I understand how it is to be administered.
6. I understand the prescription will come from a compounding pharmacy, which is not FDA approved. I have been told that the manufacturing facility itself is FDA monitored along with third party testing on the medication itself.
7.Prices may vary and change. My charge will include my time with Juliann (in person and via communication outside of the office), supplies, and medication.
8. It has been explained to me that this medication could be harmful if taken inappropriately or without advice from the provider.
9. 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. 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
Hypersensitivity reaction
Anaphylaxis
Acute kidney injury
Chronic renal failure exacerbation
Pancreatitis
Cholelithiasis
Cholecystitis
Syncope
B. I understand that I have the following responsibilities:
1. I agree to obtain prescriptions for compounded semaglutide only from Juliann Lazzaro, APRN.
a. If I am looking to transition to a non-compounding pharmacy or seek insurance coverage, I will tell Juli in advance.