I give/do not give my permission to inform my Primary Care Provider (PCP) about the Semaglutide treatment that I am about to receive: (please click your selection below)

I hereby voluntarily consent for Carolina Wellness & Recovery, LLC (the “Practice”), through its principal, Jean Chunyo, PA-C and its designated assistants, to help me in my weight management.

I understand that my program may consist of dietary education, exercise counseling, instruction in behavior modification techniques, and may involve the use of medications. Some of these medications are controlled substances, and I have consented to the use of them as part of my treatment plan.

In order to manage my weight in the best possible manner, I understand that I may need to provide medical records from my primary care provider and other providers. I may need additional blood work and work up, as deemed necessary by the medical team, for my safe treatment. This may include evaluation of sleep apnea, metabolic syndrome management, etc. based on case by case presentation. Neither the Practice nor its team is responsible for wrong/incorrect/inaccurate information provided to them.

I understand that much of the success of the program will depend on my efforts, and that there are no guarantees or assurances that the program will be successful. I also understand that obesity may be a chronic, life-long condition that may require changes in eating habits and permanent changes in behavior and lifestyle changes,
otherwise I understand I may regain all the additional weight again.

I also understand that there are other ways and programs that can assist in decreasing body weight and to maintain weight loss without the use of the appetite suppressant/other medications (if followed), though I would probably be hungrier without the appetite suppressants/other medications and the optimal weight loss may not be achieved.

I understand that if I do not adhere to the program guidelines as recommended by the Practice and its team, the Practice may elect to discharge me from the program. It is also important that any patient of the Practice conduct themselves appropriately at all times while interacting with the Practice and its team members. The Practice
reserves the right to discharge a patient for inappropriate and/or abusive behavior. Also, any patient who is a “no show” for his/her appointment (i.e. does not appear for the appointment without the required advanced notice and/or good cause) more than three (3) times may also be discharged, if deemed appropriate by the Practice. In addition, the Practice reserves the right to make changes to their services, and weight management program or terminate the program at any time.

The main benefits may include:

1. Semaglutide is 94% similar to natural human GLP-1 and therefore acts as a physiological regulator of appetite and thereby reduces food intake by reducing feelings of hunger and increasing feelings of fullness/satiety.

2. Semaglutide is a newly licensed medication indicated for the treatment of type-2 diabetes. It is currently undergoing clinical trial to gain a license for the treatment of obesity. In the meantime, your medical practitioner may prescribe this medication for you 'off-label'.

3. For long term success the treatment needs to be combined with lifestyle changes including nutritional, exercise and behavioural habits.

4. Weight loss can lead to secondary benefits by improving weight loss related health problems such as cardiovascular risk factors (including hypertension, blood glucose levels and waist circumference) and physical health-related quality of life.

I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent.

Since every human being is unique, we cannot guarantee any specific result from Semaglutide treatment. Medication and or medical conditions may have a negative impact on the outcomes as well as lifestyle factors. Treatment should be discontinued after 12 weeks if the patient has not lost at least 5% of their initial body weight.

Patients need to follow the instructions carefully as provided separately in the patient instruction sheet. Patients must agree to notify their practitioner of any contraindications or side effects of the treatment.

While using a GLP-1 RA it is highly recommended that you:

• Eat a fibrous diet. Focus on fruits and vegetables that are high in fiber.
• Eat small high protein meals as digestion is slowed down while on this medication.
• Avoid foods high in fat as they take longer to digest.
• Drink at least 32oz of water a day to avoid constipation and dehydration. 

If you suffer from a medical or pathological condition, you need to consult with an appropriate healthcare provider such as your PCP or Consultant. If you are under the care of another healthcare provider, it is important that you inform your other healthcare providers of your use of Semaglutide. If you are using medications of any kind, you are required to alert us.

Note: If you have any physical or emotional reaction to Semaglutide treatment, discontinue use immediately, and contact your practitioner to ascertain if the reaction is adverse or an indication of the natural course of the body's adjustment to the treatment.

1. Alternatives to Semaglutide therapy are surgical procedures, oral medical treatments (including Orlistat) and / or dietary and lifestyle changes alone.

2. Several weeks to months of treatment may be required depending on your individual response.

3. If a missed dose is more than 5 days late, the missed dose should not be taken, and the next dose should be taken at the normal time.

4. It is essential to combine eating, exercise and behavioral modifications with Semaglutide.

5. Semaglutide should not be used in combination with another GLP-1 receptor agonist, insulin or insulin secretagogues (such as sulfonylureas) due to the risk of hypoglycemia.

6. Upon initiation of Semaglutide treatment in patients on warfarin or other coumarin derivatives, more frequent monitoring of International Normalized Ratio (INR) is recommended.

7. Semaglutide causes a delay of gastric emptying and has the potential to impact the absorption of concomitantly administered oral medications. Monitor for potential consequences of delayed absorption of oral medications concurrently administered with Semaglutide.

8. There are several special warnings and precautions for use of Semaglutide including warnings on pancreatitis, cholelithiasis and cholecystitis, thyroid disease, heart rate, dehydration and hypoglycemia in people with type 2 diabetes.

9. Thyroid adverse events, such as goiter have been reported in particular in patients with pre-existing thyroid disease. Semaglutide should therefore be used with caution in patients with thyroid disease.

10. A higher rate of cholelithiasis and cholecystitis (gallstone and gallbladder disease) has been observed in patients treated with Semaglutide. 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.

11. Signs and symptoms of dehydration, including renal impairment and acute renal failure, have been reported in patients treated with Semaglutide. Patients treated with semaglutide 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.

12. Acute pancreatitis has been observed with the use of Semaglutide. Patients and their carers should be told how to recognize signs and symptoms of acute pancreatitis and advised to seek immediate medical attention if symptoms develop. If pancreatitis is suspected, semaglutide should be discontinued; if acute pancreatitis is confirmed, semaglutide should not be restarted.

13. Semaglutide may cause dose-dependent and Treatment-duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Semaglutide causes thyroid C-cell tumors, including medullary thyroid carcinoma (cancer, MTC), in humans, as the human relevance of semaglutide-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.)

 

The most common Semaglutide side effects include but are not limited to:

• Nausea
• constipation
• decreased appetite
• dizziness
• hypoglycemia
• vomiting
• dyspepsia
• abdominal pain
• diarrhea
• headache
• fatigue
• increased lipase

Nausea is the most common side effect when first starting Semaglutide, 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 healthcare professional if you have any side effect that bothers you or that does not go away.

 

Do not take Semaglutide if any of the below contraindications apply to you:

1. Aged under 18 or above 75

2. Severe renal/kidney impairment (with eGFR of 15 or below) or a history of renal disease

3. Severe hepatic/liver impairment

4. Personal or family history of medullary thyroid cancer (MTC)

5. Hypersensitivity to Semaglutide or to any of the excipients: disodium phosphate dihydrate, propylene glycol, phenol, and water for injection.

6. Concurrent treatment with any other products for weight management

7. Weight problems related to endocrinological or eating disorders

8. Concurrent insulin or sulfonylurea

9. Patients on warfarin (more frequent INR monitoring required)

10. Concurrent use of any medicinal products with may cause weight gain

11. Pregnancy, breastfeeding or trying to/planning to become pregnant.

12. Congestive heart failure

13. History of pancreatitis, gallbladder disease, inflammatory bowel disease, diabetic gastroparesis.

 

By signing below, I am acknowledging that:

• I am either the patient or the patient's personal representative;
• I have received a copy of the "Notice of Privacy Practices" for Carolina Wellness and Recovery; and
• I understand that I may contact the person named in the Notice if I have questions about the content of the Notice.

• Semaglutide for weight loss is currently FDA approved only under the brand name, Wegovy.

• Our weight loss program does not use the brand name Wegovy and therefore is not using a FDA approved medication for weight loss. We use Semaglutide that is compounded with other components such as Vitamin B12 or other compounds.

• It is important to note that the studies conducted on Semaglutide for weight loss were not done with a compounded version and the effectiveness of Semaglutide in a compounded version has not been established.

• Semaglutide is more commonly associated with nausea, heartburn, vomiting and constipation. Less common side effects include abdominal pain, gastroparesis, pancreatitis, gallbladder stones or inflammation, acute kidney injury, low blood glucose, electrolyte imbalance, diabetic retinopathy, headache, fatigue and suicidal ideation.

• Semaglutide should not be used in patients with a history of or family history of medullary thyroid cancer or multiple endocrine neoplasia.

• Semaglutide should not be used if the patient has a history of insulin-dependent diabetes, diabetes utilizing sulfonylureas, patients with history of low blood sugar (hypoglycemia) or patients with acute or recent Pancreatitis or active gall bladder disease.

• Although Semaglutide under the supervision of a physician is generally considered safe for use in the appropriated screened patient, the long-term effects of this medication on diseases such as pancreatic, thyroid or other cancers or diseases is not well known.

• I am aware that other unforeseeable complications could occur. I do not expect the clinic to anticipate and or explain all risk and possible complications. I rely on them to exercise judgment during the course of treatment. I understand the risks and benefits of the treatment and have had the opportunity to have all of my questions answered.

• I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. At any stage during the treatment, I have the right to request that the procedure is terminated, however l accept that l will not be reimbursed once supply has commenced.