Whole Home Health
Terms of Service
(DBA: My Whole Health Solutions)

Consent To Treatment:

GIP and/or GLP-1 RA Weight Loss Injections

Informed Consent Instructions:

This is an informed consent document to provide written information about the above named treatment regarding risks, benefits, and alternatives. It is important that you understand the information provided to you prior to proceeding with this treatment; please ask your healthcare professional any/all questions prior to signing this consent form.

I am hereby stating/attesting to my ability to read, write and understand English.

MY WHOLE HEALTH SOLUTIONS IS CONTEMPLATED FOR SPECIFIC NON-EMERGENCY MEDICAL CONDITIONS AND CONCERNS. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, PLEASE DIAL 911 OR YOUR LOCAL MEDICAL PROVIDER.
 
BY CLICKING “I AGREE,” CHECKING ANY BOX TO SIGNIFY YOUR ACCEPTANCE, USING ANY OTHER ACCEPTANCE PROTOCOL PRESENTED THROUGH THE SERVICE, OR OTHERWISE AFFIRMATIVELY ACCEPTING THESE TERMS OF SERVICE, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREE TO BE BOUND BY THESE TERMS. IF YOU DO NOT AGREE TO THESE TERMS, YOU ARE NOT PERMITTED TO CREATE AN ACCOUNT OR USE MY WHOLE HEALTH SOLUTIONS SERVICE. YOU HEREBY GRANT AGENCY AUTHORITY TO ANY PARTY WHO INDICATES ACCEPTANCE TO THESE TERMS AND CONDITIONS ON YOUR BEHALF.
 
THIS USER AGREEMENT CONTAINS A MANDATORY ARBITRATION PROVISION. UNLESS YOU TIMELY OPT-OUT OF ARBITRATION IN ACCORDANCE WITH THESE TERMS, YOU AGREE THAT DISPUTES BETWEEN YOU AND US, OR YOU AND THE MEDICAL GROUPS OR PROVIDERS, ARISING OUT OF OR RELATED TO THESE TERMS AND CONDITIONS OR THE SERVICE WILL BE RESOLVED BY BINDING, INDIVIDUAL ARBITRATION. YOU FURTHER WAIVE YOUR RIGHTS TO A JURY TRIAL AND TO PARTICIPATE IN A CLASS ACTION LAWSUIT OR CLASS-WIDE ARBITRATION.
 

INTRODUCTION:

My Whole Health Solutions. and its subsidiaries (collectively, “My Whole Health Solutions,” “we,” or “us”) owns and operates the website www.MyWholeHealthSoltions.com and may, now or in the future, own and operate a My Whole Health Solutions mobile application (collectively, the “Sites”). Your use of the Sites, any part thereof, or anything associated therewith, including the services, features, content, and applications, together with the Sites, are the My Whole Health Solutions Service (“Services”) offered by My Whole Health Solutions. and our affiliated professional entities for whom we coordinate healthcare offerings. Any products or services provided through the Sites or any affiliated website, software, or application owned or operated by My Whole Health Solutions are governed by these Terms of Service (“Terms” or “Agreement”). By accessing or using any of the My Whole Health Solutions Services, which include our affiliated professional entities, you agree to be bound by this “Agreement”, which is a legally enforceable agreement between My Whole Health Solutions, our affiliated entities, and you, the individual (“You” or “Your”). Please read this Agreement carefully as it provides the important information you will need to know about using My Whole Health Solutions Service.

Acceptance of These Terms:

Your use of My Whole Health Solutions Service is subject to this Agreement and all applicable laws and regulations. If you do not accept and agree to be bound by this Agreement in its entirety, you are strictly prohibited from visiting, accessing, registering with and/or using the Service or any information or content provided through the Service, except as necessary to review this Agreement. The Service is continually under development, and we reserve the right to revise or remove any part of this Agreement or the Service in our sole discretion at any time and without prior notice to you. Any changes to this Agreement are effective upon it being posted to the Platform. Unless otherwise indicated, any new content added to the Service is also subject to this Agreement upon posting to the Platform. If you disagree with this Agreement or any terms or conditions herein, your sole remedy is to discontinue your use of the Service. Your continued use after a change to this Agreement has been posted constitutes your acceptance of this Agreement as modified by such changes.
 

OUR RELATIONSHIP WITH YOU:

These Terms of Service (the “Terms”) apply to your use of any of My Whole Health Solutions Service for which you are enrolled or have a consultation scheduled and are further described below:

Telehealth consultations and services:
My Whole Health Solutions Service may include access to one or more professional medical organizations (“Medical Groups” or “Groups”) to provide healthcare services through the Sites. These Groups employ or contract with licensed medical providers (“Providers”) who offer certain healthcare services via My Whole Health Solutions Service. All medical providers who deliver Healthcare Services through the Sites are: (i) independent professionals contracted or employed with affiliated professional entities that coordinate with My Whole Health Solutions Services, and (ii) solely responsible for such Healthcare Services you receive. Consultations are provided by a medical Provider licensed in the state where you, the Patient, are located via a HIPAA-secure platform. Provider consultations may provide diagnoses and prescribe medication, if clinically appropriate. Prescriptions can be issued for both controlled and non-controlled substances regulated by the DEA, encompassing both commercially available and compounded medications.

ELECTRONIC COMMUNICATIONS: When you enroll and use My Whole Health Solutions Service, you are consenting to conduct business electronically with My Whole Health Solutions Service and engage in health-oriented activities with medical providers and professional entities affiliated with My Whole Health Solutions. Such processes have the same force and effect as your written signature. You agree and consent to My Whole Health Solutions, its affiliates, subsidiaries, and other affiliated professional entities sending you disclosures, messages, notices, and other communications to your designated mobile phone and email account. You understand and agree that My Whole Health Solutions Service is not responsible for the security or privacy of communications services you use to receive the aforementioned messages and emails sent via My Whole Health Solutions Service. You further understand and agree that it is your sole responsibility to monitor and respond to these messages and emails and that neither My Whole Health Solutions nor the Medical Group or any Provider will be liable for any loss, injury, or claims of any kind resulting from your failure to read or respond to these messages or for your failure to comply with any treatment recommendations or instructions from the Medical Group or your Provider(s).
If you do not agree with any of these Terms or our Privacy Policy, you may not use the Sites or My Whole Health Solutions Service.
If prescribed, medication fulfillment is offered through compounded pharmacies. (“Pharmacies”) licensed appropriately to dispense medications to the state jurisdictions which are served by My Whole Health Solutions Service. You agree and understand that your prescription(s) may be filled by and transferred between any of the Pharmacies, and you agree that My Whole Health Solutions Service may take these actions on your behalf. My Whole Health Solutions does not control or interfere with any professional service provided by the Pharmacies, and each is solely responsible for their provision of professional services rendered via My Whole Health Solutions Service.
By accepting this Agreement, you acknowledge and agree that any services you receive from the Pharmacies, Medical Groups or Providers through the Sites are also subject to this Agreement, and that the Labs, Pharmacies, Medical Groups and Providers are third-party beneficiaries of this Agreement.

THIRD-PARTY GOOD AND SERVICES: Labs, Third-Party Pharmacies, Medical Groups, and Providers (collectively, “Third-Parties”) may provide services or products (“Third-Party Goods and Services”) through My Whole Health Solutions Service. Your use of any Third-Party Goods and Services and any interactions with Third-Parties, including payment and delivery of goods or services, and any other terms, conditions, warranties or representations associated with such use or interactions, are solely between you and such Third-Parties. Should any dispute arise between you and any Third-Party, any other User or any other entity or individual, you understand and agree that My Whole Health Solutions is under no obligation to become involved in such dispute, and you hereby release and indemnify My Whole Health Solutions, and their respective corporate parents, subsidiaries, and affiliates, and all of their respective contractors, directors, officers, employees, representatives, proprietors, partners, shareholders, servants, principals, agents, predecessors, successors, assigns, accountants, and attorneys (collectively, “My Whole Health Solutions Parties”) from any and all claims, demands, or damages (actual or consequential) of every kind or nature, known or unknown, suspected and unsuspected, disclosed or undisclosed, arising out of or in any way related to such disputes or the Service or the features and services therein. IF YOU ARE A CALIFORNIA RESIDENT, YOU WAIVE CALIFORNIA CIVIL CODE SECTION 1542, WHICH STATES: “A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS THAT THE CREDITOR OR RELEASING PARTY DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE AND THAT, IF KNOWN BY HIM OR HER, WOULD HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR OR RELEASED PARTY.”

My Whole Health Solutions shareholders, directors, officers, employees, contractors or agents (collectively, “My Whole Health Solutions Stakeholders”) may have a financial interest in one or more Third-Parties and may profit from your use of the Third-Parties or the sale of Third-Party Goods and Services.

 

 

TELEMEDICINE PATIENT CONSENT

OUR PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. DO NOT PROCEED WITH CLINICAL SERVICES USING THE HENRY MEDS PLATFORM IF YOU BELIEVE YOU ARE HAVING A MEDICAL EMERGENCY. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM.
 
PURPOSE: 

The purpose of "Telemedicine Consent Form" is to get the patient's consent in order to participate in appointments of telemedicine cares.
You are reviewing and acknowledging this Telehealth Informed Consent because you are seeking Healthcare Services utilizing telehealth technologies with My Whole Health Solutions.This Telehealth Informed Consent does not modify or supersede any Terms of Use, Privacy Policy, or Notice of Privacy Practices of My Whole Health Solutions or the Providers, rather it supplements these terms and documents. By creating an account, starting a consult, clicking “get started,” checking a related box to signify your acceptance, or using any other acceptance protocol presented through the My Whole Health Solutions Platform, you indicate that you have reviewed the risks as described herein of receiving services utilizing telehealth technologies and consent to receiving the services. A record of this Telehealth Informed Consent is maintained in the files and records of the applicable Provider delivering your services, and your on-going participation in services with the My Whole Health Solutions Medical Group using telehealth technologies serves as an on-going acknowledgement of your acceptance of this Telehealth Informed Consent and updates at such time the representations you provide herein.

The medical information related to history, records and tests of the patient will be discussed during the telemedicine appointment with video and audio.

ACCESS:

The patient accepts that he/she needs access to PC, laptop, or mobile device and a good internet connection in order to have an efficient telemedicine appointment.
  

PATIENT RIGHTS:

The patient can withdraw his/her consent at any time and can ask the questions related to telemedicine appointments and technical requirements for telecommunication.

PATIENT ACKNOWLEDGEMENTS:

By accepting this Telehealth Informed Consent, you acknowledge you understand and consent to the following:

1). You have reviewed this Telehealth Informed Consent carefully, and understand there are risks, limitations, and benefits of utilizing telehealth.

2). You understand that the electronic nature of the telehealth services means that there is a greater risk to the privacy of my health information.

3). In most, if not all cases, my Provider may be a nurse practitioner or physician assistant and not a physician.

4). Persons may be present during the telehealth visit other than my Provider in order to operate the telehealth technologies and/or for language translation assistance, if requested. If another person is present during the telehealth visit, I will be informed of the individual’s presence and his or her role.

5). I understand that information I provide as part of any telehealth offering is viewed as accurate, true, and complete.

6). I understand that in certain instances, and in compliance with applicable law, my Provider may determine that it is appropriate to provide my Healthcare Services asynchronously via store-and-forward technology. In such instances, my Provider and I will communicate electronically through the DOXIMITY/DOXY.ME platform and not via telephone or video. I agree that if my provider makes that determination, I would like to receive Healthcare Services in this manner.

7). I understand that there is no guarantee that I will be given a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgment of my Provider. I understand that while the use of telehealth may provide benefits to me, no such benefits or specific results can be guaranteed, and my condition may not improve.

8). I understand there is a risk of technical failures during the telehealth encounter beyond the control of Colchis Medical Group and my Provider(s)

I AGREE TO HOLD HARMLESS MY WHOLE HEALTH SOLUTIONS AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS,OFFICERS,REPRESENTATIVES, ASSIGNS, PREDECESSORS, AND SUCCESSORS, INCLUDING WHOLE HOME HEALTH AND MY WHOLE HEALTH SOLUTIONS AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES.

9). I understand that certain diagnostic testing services, including laboratory products and services offered through the Adonis Health Platform to support the Healthcare Services of Providers, may contain defects, including ones which may limit functionality or produce erroneous results, any or all of which could limit or otherwise impact the quality, accuracy and/or effectiveness of the medical care or other services that I receive from my Provider(s).

10). I understand the My Whole Health Solutions company makes available a specific set of services and I may need to seek other resources for my other health needs. There is no guarantee that I will be approved for treatment by a Provider. My Provider reserves the right to deny care for any reason if, in the professional judgment of my Provider, the provision of the services, including when provided via telehealth is not medically or ethically appropriate.

11). I understand that by using the My Whole Health Solutions Health Platform I am not always speaking or messaging with my Provider in real-time, and there may be a delay before my messages or information is reviewed. I understand that I must check my email, and the provided Health Platform for messages because this is the way that my Provider will communicate important information to me. I understand that if I do not check the Adonis Health Platform regularly, then my services may be delayed.

12). I understand that I have the opportunity to discuss the use of telehealth, including the Healthcare Services, with my Provider(s), including the benefits and risks of such use and the alternatives to the use of telehealth. I have the right to withdraw my consent to the use of telehealth in the course of my care, without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which I am entitled, but I understand that the Providers who provide Healthcare Services do not offer in-person treatment.

13). I understand that I have access to my medical record pertaining to the Healthcare Services of Providers in accordance with applicable laws and regulations and that my primary care provider, or other treating provider, may obtain copies of my health and wellness information with my consent.

 

I consent to treatment by My Whole Health Solutions.

BENEFITS & RISKS MAY VARY.

Treatment benefits will vary by individual, but may include: reduced appetite, feeling a sense of fullness for longer durations after eating (delayed gastric emptying), and increased fat-burning mechanisms which may result in weight loss.

Additional therapeutic benefits related to weight management may include: improved blood sugar levels and reduced risk of adverse cardiovascular events.

I consent to treatment by Whole Health Solutions using Semaglutide GLP1 RA or Tirzepatide GIPGLP1 RA injections for elective chronic weight management treatment Treatment benefits will vary by individual but may include reduced appetite feeling a sense of fullness for longer durations after eating delayed gastric emptying and increased fatburning mechanisms which may result in weight loss Additional therapeutic benefits related to weight management may include improved blood sugar levels and reduced risk of adverse cardiovascular events

Purpose of Treatment and General Information:

What is Semaglutide or Tirzepatide Weight Management Treatment: Semaglutide or Tirzepatide weight management injections are used for weight loss along with a diet and exercise plan. These injections are delivered beneath the surface of the skin (subcutaneously) for chronic weight management in adults with obesity (BMI >30) or who are overweight (BMI >27) with at least one weight-related condition, including high blood pressure, diabetes type 2, and/or high cholesterol. Semaglutide mimics a glucagon-like peptide hormone called GLP-1, which slows the movement of food from the stomach into the small intestine, helping to reduce appetite and increase satiety after eating. Tirzepatide mimics both GIP and GLP-1 receptor agonist hormones, which trigger insulin creation, sensationof fullness, and appetite reduction. Additional treatment benefits associated with these weight loss injections may include: improved A1C and blood sugar levels by increasing insulin (a hormone that lowers blood sugar levels) and inhibiting glucagon (a hormone that raises blood sugar); improved blood pressure; reduced risk of major adverse cardiovascular

What To Expect During Treatment:

Your treatment provider will begin with a consultation that includes a formal review of your recent lab values and will review your health and medication history to ensure you are a good candidate for weight loss injections. You will be counseled on nutrition and exercise recommendations to be used along with Semaglutide injections for chronic weight management, including reducing calories and increasing physical activity. You will be taught how to perform these injections at home just below the surface of the skin (subcutaneously) and will be prescribed a dosage that is adjusted for your individual needs, in accordance with your treatment plan. There is no downtime associated with this treatment. You may feel minor discomfort during the injection, similar to an insulin injection. Common side effects include: nausea, vomiting, diarrhea, indigestion, abdominal pain, constipation, fatigue, and dizziness. Multiple injections will be needed over the course of months to achieve desired results.

Dosing adjustments will be made by your treatment provider based on your body's response and any side effects you're experiencing. Treatment Regimen: Typical treatment regimen includes an initial series of weekly injections for 90 days, including monthly follow-ups and lab work. You will return to the office for follow-up visits and dose adjustments once per month until you've reached your weight loss goals. Maintenance: Once you have achieved your weight loss goal, you may be weaned down to lower dosing of Semaglutide or Tirzepatide at specified intervals and/or given a maintenance protocol. Maintenance injections may be necessary to maintain desired results. Iunderstand the treatment goal is weight loss. I understand that repeated injections will be necessary in order to achieve desired results and that / will need to return to the office weekly for injections, as well as maintain regular follow-ups with my treatment provider. 

Semaglutide (GLP-1 RA) or Tirzepatide (GIP/GLP-1 RA)Weight Management Treatment Consent:

By signing below, I acknowledge and agree: I have fully disclosed on my client intake form and during face-to-face or Tele-Health consultation with treatment provider any and all medications, previous complications, planned or previous surgeries, sensitivities, allergies, or current conditions that may, or may not, affect my treatment. I have read the foregoing informed consent for Semaglutide or Tirzepatide Weight Management Treatment; I agree to the treatment and all known and unknown associated risks.

I will recieve and will follow all aftercare instructions.

I acknowledge that no guarantee has been given by anyone as to the results that may be obtained. For women of childbearing age: by signing below I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of this treatment and that I am not breastfeeding. Furthermore, I agree to keep my treatment provider informed should I become pregnant during the course of this treatment. It has been explained to me in a way that I understand: There may be alternative procedures or methods or treatments. There are risks, known and unknown, to the procedure or treatment proposed. I have had ample opportunity to ask any questions regarding Semaglutide or Tirzepatide Weight Management Treatment benefits, side effects and after care, and all of my questions have been answered to my satisfaction. I believe I have adequate knowledge to understand the nature and risk of the treatment to which I am consenting. By signing below, I am consenting to undergo this, and any subsequent Semaglutide or Tirzepatide Weight Management Treatment for 365 days from the date below, with all aforementioned understood by me. I release the overseeing clinic Nurse Practitioner, the person performing the Semaglutide or Tirzepatide Weight Management Treatment, and the clinic facility from liability associated with treatment.

 

Semaglutide and Tirzepatide injection benefits may include:

Weight reduction and/or weight management Improved blood sugar Reduced risk of adverse cardiovascular events related to obesity.

I understand the possible benefits of this weight management treatment.

Alternative options exist:

Alternative forms of non-surgical and surgical treatment consist of: No treatment whatsoever, diet and lifestyle modifications, increased physical activity, other pharmaceutical weight management therapies, and bariatric surgery. Every procedure will involve a certain amount of risk. An individual's choice to undergo a procedure is based on the comparison of the risk to the potential benefit. Although most patients do not experience adverse complications, you should discuss your concerns and potential risks with your treatment provider in order to make an informed decision.

It has been explained to me that alternative treatments are available.

Possible Risks and Side Effects:

Possible side effects/risks of Semaglutide and Tirzepatide Weight Management Treatment may include:

1. General Side Effects: I understand there is a risk of discomfort, pinpoint bleeding, pain at the injection site, bruising, allergic reaction, damage to deeper structures, or gastrointestinal side effects that may occur.

2. Gastrointestinal Upset: The most common side effects of treatment include: Nausea, vomiting, diarrhea, constipation, indigestion, belching, feeling bloated, and abdominal pain. Slow titration of dosing adjustments may help prevent these side effects, or dosing adjustments may be required if side effects persist. Your treatment provider can provide you with medications and/or recommendations to help alleviate these side effects, including suggesting eating slowly, eating bland foods, avoiding greasy foods, and avoiding lying down immediately after eating.

3. Fatigue, Dizziness, and Headache: Some patients experience fatigue, dizziness, and/or headache, which may be a result of low blood sugar. If you experience these symptoms, please discuss this with your treatment provider.

4. Low Blood Sugar: There is an increased risk of low blood sugar (hypoglycemia), especially in patients with type 2 diabetes taking medications such as insulin or sulfonylureas. Symptoms may include: dizziness, headache, lightheadedness, rapid heartbeat, mood changes, irritability, weakness, shakiness, slurred speech, confusion, or hunger. Talk to your healthcare provider about how to recognize and treat low blood sugar. If you have diabetes type 2, you should check your blood sugar as directed.

5. Increased Heart Rate: You may experience an increased heart rate while at rest. Please contact your treatment provider if you experience your heart racing or if you feel a pounding sensation in your chest that lasts for several minutes or longer. Tell your treatment provider if these symptoms persist or become bothersome.

8. Bleeding/Bruising/Redness: It is possible to experience minor pinpoint bleeding during and after injection. Bruising in soft tissues may occur, as well as minor redness or swelling.

9. Infection: Although rare, if an infection occurs as a result of treatment at injection site, additional treatment including antibiotics or an additional procedure may be necessary.

10. Depression, Suicidal Thoughts, Mood Changes (Semaglutide): Some weight loss medications, including Semaglutide, may increase the risk of depression and/or suicidal ideations. Any new or worsening changes in mood, behaviors, thoughts, or feelings should be reported to your healthcare provider right away.

11. Pancreatitis: Inflammation of the pancreas (pancreatitis) may occur. If you experience persistent severe pain in your stomach, with or without vomiting, please contact your treatment provider right away.

12. Gallbladder Inflammation and/or Gallstones: You may experience gallbladder issues, including gallstones. Signs/symptoms of gallbladder inflammation and/or gallstones include: pain in your upper stomach, yellowing of skin and/or eyes, clay-colored stools, and fever. Please contact your treatment provider right away if you experience these symptoms. Some gallbladder issues may required additional treatment incurred at your expense, and which may include surgical intervention and/or hospitalization.

13. Gastrointestinal Blockage or Disease: Although rare, there is a risk of stomach blockage (known as a an ileus) resulting from decreased intestinal movement of food and fluids. Symptoms include persistent, unrelieved constipation, stomach cramping and swelling, loss of appetite, inability to pass gas, and vomiting. An ileus can be serious and life threatening if left untreated; treatment may include hospitalization and/or surgery incurred at your expense.

14. Dehydration and Acute Kidney Injury and/or Renal Impairment: There is a potential risk for dehydration leading to acute kidney injury and/or worsening renal impairment due to adverse gastrointestinal reactions (nausea, vomiting, diarrhea It is important to drink adequate fluids to help reduce your risk of dehydration, which may cause kidney impairment.

15. Thyroid C-cell Tumors: There is a potential risk for thyroid C-cell tumors when taking Semaglutide. Please report any signs/symptoms of thyroid tumors to your treatment provider, including: persistent hoarseness, shortness of breath, mass in neck, and/or difficulty swallowing.

16. Changes in Vision: Patients with diabetic retinopathy may experience changes in vision while taking Semaglutide. This may be caused by a rapid improvement in glucose control, which could lead to temporary worsening of retinopathy, however, the effect of long-term glycemic control on diabetic retinopathy has not yet been studied. Please report any changes in vision to your treatment provider.

This list is not exhaustive of all possible risks associated with Semaglutide and Tirzepatide weight management treatment, as there are both known- and unknown- side effects and risks associated with any Allergic Reaction or Hypersensitivity: Although rare, allergic reactions or serious hypersensitivity may occur. Signs of allergic reaction may include: hives, difficulty breathing, swelling of your face, lips, tongue, or throat; additional treatment may be necessary should an allergic reaction occur. 

I have read and understand possible risks, side effects, and complications.

Financial Responsibility:

By signing below, I acknowledge that I understand the regular charge applies to all treatments. I understand- and agree- that all services rendered to me are charged directly to me and that I am personally responsible for payment.I acknowledge that most insurances do not cover the cost of weight loss injection treatment, and therefore, I am required to pay for services and medication out of pocket. In the event that I am not satisfied with my results, I agree not to seek a refund for Semaglutide or Tirzepatide treatment services rendered, as I am fully aware that there is no implied or explicit guarantee of results, as stated in the acknowledgement above. I further agree in the event of non- payment and/or reversal of payment via a credit card dispute that I initiate, I will bear the cost of collection fees, and/or court fees, and/or any reasonable legal fees resulting from such instance.

Off-Label Use Informed Consent: Tirzepatide for Weight Management

Acknowledgement of Off-Label Use Iunderstand Tirzepatide is currently approved by the Food and Drug Administration for the intended purpose of type 2 diabetes management. Regardless, I choose to receive Tirzepatide subcutaneous injections for the purpose of weight management and I am willing to accept the potential risks, side effects- both known and unknown- that my treatment provider has discussed with me. I further acknowledge that there may be unknown risks, side effects, and outcomes not listed above in the "Known Risks and Side Effects" section and that long-term effects and risks of Tirzepatide for weight management may not be known.

Consent to Off-Label Use Treatment

I understand that Tirzepatide and Semaglutide is not currently a standard form of treatment for weight loss management. I hereby confirm that the nature and purpose of the aforementioned treatment may be considered medically unnecessary and/or experimental and not a currently indicated treatment for the purpose I am seeking. The risks involved with this treatment and the possibilities of complications have been explained to me. I fully understand that the treatment to be provided may be considered experimental and unproven by scientific testing and peer-reviewed publication. By signing below, I am consenting to undergo off-label use Tirzepatide and Semaglutide treatments, with all aforementioned understood by me. I hereby release the overseeing clinic physician, the person performing the treatment, and the clinic facility from liability associated with treatment.

Contraindications To Treatment:

Semaglutide and Tirzerpatide injections are contraindicated in those who:

Are pregnant or are breastfeeding.

Have ever had Medullary Thyroid Cancer (MTC) (this includes a family history of MTC) have Multiple Endocrine Neoplasia Syndrome type 2 (MEN 2).

Have ever had a serious allergic reaction to Semaglutide or Tirzerpatide or any of the ingredients in Semaglutide or Tirzepatide, including compound formulations, which may include: vitamin b12 and/or vitamin b6.

Please tell your treatment provider if you have any other medical conditions, including the following, as Semaglutide or Tirzepatide injections may not be suitable for you:

Plan to become pregnant (you should stop Semaglutide and Tirzepatide 2 months prior to pregnancy)

Have, or have had, problems with your pancreas or kidneys have type 1 diabetes, type 2 diabetes, or a history of diabetic retinopathy.

Are taking certain medications, including: sulfonylureas or insulin have, or have had, depression, mental health issues, and/or suicidal thoughts.

I have read and understand the contraindications to treatment and affirm that I do not have any of the aforementioned conditions and have disclosed pertinent medical history to my treatment provider.

Possible Medication Interactions and/or Reduced Effectiveness

Prescription and OTC Medication, Herbal and Nutritional Supplements, and Minerals: I understand that certain herbal products, medications, and supplements may affect the way Semaglutide or Tirzepatide works, resulting in reduced efficacy of treatment and/or additional side effects.

Semaglutide and Tirzepatide slows stomach emptying and can affect absorption of oral medications medicines, which may affect the way certain medications work or the effectiveness of medications.

I have read and understand possibility of interactions with treatment.

I deny the possibility of being pregnant at this time. I understand that Semaglutide or Tirzepatide may harm an unborn baby and the safety of the use of Semaglutide or Tirzepatide during pregnancy and breastfeeding has not been studied. If I am unsure of pregnancy, I will request a pregnancy test prior to my treatment. I further acknowledge that I should stop using Semaglutide at least 2 months prior to becoming pregnant.

I deny the possibility of being pregnant at this time and acknowledge risk of harm to unborn child while taking Semaglutide or Tirzepatide. Initials:

In some situations, it may not be possible to achieve desired weight loss results.

It is also possible that Semaglutide or Tirzepatide injections may fail to produce any reduction in weight. Should complications occur, additional- or other- treatments may be necessary. Semaglutide and Tirzepatide injections are not a permanent solution for weight management, and must be maintained with lifestyle and diet modifications; you may also require maintenance injections to maintain desired weight. As a weight management treatment, it is recommended to allow at least 90 days of treatment to achieve results. Duration of results is unknown and not guaranteed.

I have read and understand results are not guaranteed. 

Please call your treatment provider right away or seek emergency medical treatment if you experience any of the following: signs of allergic reaction:

rash, hives, itching, peeling skin, difficulty swallowing, swelling of the mouth, face, lips, tongue, or throat, or tightness in the chest signs of kidney issues: inability to pass urine, change in urine output, blood in urine, sudden weight gain signs of gallbladder issues: pain in upper right abdomen, changes in stool, dark urine, yellow skin, fever with chills, pain in shoulder or between shoulder blades signs of pancreas issues: severe stomach pain or severe back pain and vomiting signs of stomach blockage: constipation, stomach swelling and pain, vomiting, inability to pass gas Please call your treatment provider or seek medical treatment if you experience: severe dizziness or passing out or change in eyesight inability to keep food down or take liquids by mouth increased heart rate or pounding in chest low blood sugar: dizziness, shaking, weakness, rapid heart rate, confusion, hunger, mood changes new or worsening behavior or mood changes, including depression or thoughts of suicide Notify all providers that you are taking Semaglutide or Tirzepatide, especially prior to any surgery, including dental work. You may need to discontinue use up to 2 weeks prior to surgery or procedures.

Liability Release Related to Adverse Effects

I assume full liability for any adverse effects that may result from the non-negligent administration of the proposed treatment. I waive any claim in law or equity for a redress of any grievance that I may have concerning- or resulting from- the treatment, except as that claim pertains to the negligent administration of this procedure.

I agree to assume full liability for any adverse effects of treatment.

I acknowledge that elective supplementation therapies, including, but not limited to Semaglutide or Tirzepatide Weight Management Treatment, may be considered medically unnecessary. It may or may not mitigate, alleviate, or cure the condition for which it has been prescribed. This treatment has been recommended to me in the belief that it is of potential benefit and its use will quite probably improve the condition for which I am under treatment for. Based on the risks and potential benefits of this proposed treatment, I have elected to receive this proposed treatment by providers and staff at Your Business Name Here.

I understand that I may suspend or terminate my treatment at anytime by informing my medical provider. I assume full liability for any adverse effects that may result from the non-negligent administration of the proposed treatment. I waive any claim in law or equity for redress of any grievance that I may have concerning or resulting from the procedure, except as that claim pertains to negligent administration of this procedure. The risks involved and the possibilities of complications have been explained to me. I fully understand and confirm that the nature and purpose of the aforementioned treatment to be provided may be considered unproven by scientific testing and peer- reviewed publications and therefore may be considered medically unnecessary or not currently indicated.

Therefore, in consideration for any treatment received, I agree to unconditionally defend, hold harmless and release from any and all liability the company and the individual that provided my treatment, the insured, and any additional insured's, as well as any officers, directors, or employees of the above companies for any condition or result, known or unknown, that may arise as a consequence of any treatment that I receive.

I understand and agree that any legal action of any kind related to any treatment I receive will be limited to binding arbitration using a single arbitrator agreed to by both parties.

 

By signing below, I acknowledge and agree: I have carefully read the information on this page and understand that I may be giving up some important legal rights by signing.