INFORMED CONSENT for SEMAGLUTIDE:
Mounjaro (tirzepatide), Wegovy/Ozempic (semaglutide), Rybelsus (semaglutide tablet), Trulicity (duraglutide), Saxenda (liraglutide)
The following consent forms apply to the above GLP-1 receptor medications and variations received through both commercial and compound pharmacy.
As of January 1st, 2023, only Wegovy has been approved by the FDA as an anti-obesity treatment. Therefore, other options/forms are considered "off-brand" use when used for weight-loss. Semaglutide prescriptions received from a compound pharmacy (or not a name brand listed above) are not an FDA approved treatment.
QUALIFICATIONS:
A BMI of ≥ 27 with at least one weight-related comorbid condition OR a BMI of ≥ 30
No previous history of Type 1 diabetes, pancreatic, kidney, thyroid, or liver disease.
Labwork within 1 year including: CMP, TSH, Lipid Panel, optional HbA1C required before refill
If you take birth control pills by mouth, it may not work as well while using these medications.
Do not use if you or any of your family have ever had medullary thyroid carcinoma (MTC).
Do not use if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
Do not use while pregnant or planning for pregnancy. Do not use if you have a history of suicidal thoughts or ideation.
The most common side effects include: nausea, diarrhea, decreased appetite, vomiting, constipation, indigestion, and stomach (abdominal) pain. These medications may cause tumors in the thyroid, including thyroid cancer. Pancreatitis, hypoglycemia, kidney problems, allergic reactions, changes in vision, stomach and gallbladder problems are also potential side effects.
Watch for possible symptoms, such as a lump or swelling in the neck, hoarseness, trouble swallowing, severe abdominal pain or shortness of breath.
INFORMED CONSENT for VITAMIN B-12 LIPOTROPIC INJECTIONS:
Vitamin B-12 helps maintain good health and has been shown to be beneficial in helping to: Reduce stress, fatigue, improve memory and cardiovascular health, and maintain a good body weight. It can also assist the body in converting proteins, fats and carbohydrates into energy and is necessary for healthy skin and eyes. Amino Acids help the liver to cleanse the body of toxins and assist the body in metabolizing fat and cholesterol. They may also be helpful in reducing fatigue and the symptoms of allergies.
B12 and Amino Acid Injections are better absorbed by the body since they go directly into the blood stream. Alternatives to these injections are oral vitamins which are supplied in-office for purchase.
B12 and Amino Acid Injections common side effects include but are not limited to:
Risks: I understand there is risk of mild diarrhea, upset stomach, nausea, a feeling of pain and a warm sensation at the site of the injection, a feeling, or a sense, of being swollen over the entire body, headache and joint pain.
If any of these side effects become severe or troublesome I will contact my physician immediately.
I understand that although rare Vitamin B12 and Amino Acid injections can result in serious side effects. Although this is a relatively rare occurrence, anyone taking vitamin B12 or Amino Acid injections should be aware of the possibility. Uncommon side effects are much more serious than the common side effects of B12 and Amino Acid injections, and such side effects should be reported to a physician to be evaluated for seriousness. Uncommon and dangerous side effects include:Rapid heartbeat, chest pain, heart palpitations, flushed face, restlessness, muscle cramps and weakness, difficulty breathing and swallowing, dizziness, confusion, rapid weight gain, tight feelings in the chest, hives, skin rashes, shortness of breath when there is no physical exertion and unusual wheezing and coughing.
Before starting vitamin B12 or Amino Acid injections I will make sure to tell my Physician if I am pregnant, lactating or have any of the following conditions:Leber’s Disease, Kidney disease, Liver disease, An infection, Iron deficiency, Folic acid deficiency, Receiving any treatment that has an effect on bone marrow, Taking any medication that has an effect on bone marrow, An allergy to cobalt or any other medication, vitamin, dye, food or preservative
I understand that certain herbal products, vitamins, minerals, nutritional supplements, prescription and non-prescription medications may result in side effects when they interact with the B12 or Amino Acid Injection.
Treatments: Typically every 5-7 days or as determined by provider
I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I further agree in the event of nonpayment, to bear the cost of collection, and/or Court cost and reasonable legal fees, should this be required.
By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks. I hereby give consent to perform this and all subsequent B12 and Amino Acid Injections with the above understood. I hereby release the doctor, the person injecting the B12 and Amino Acids, and the facility from liability associated with this procedure.
You have the right, as a patient, to be informed about your condition and how integrative and alternative medicine may be applied in a treatment plan. This disclosure is intended to provide an opportunity for you to make an informed decision so that you may give or withhold your consent to treatment that may be considered unconventional by physicians trained only in the United States. NOTICE: Refusal to consent to the integrative and alternative procedure(s) shall not affect you right to future care or treatment.
I voluntarily request that 1 Stop Doc, LLC treat my condition (or the condition of the person for whom I am responsible) as described below).
I understand that some of, or all of the following integrative and alternative treatments are planned for me (or the person for whom I am responsible), and I voluntarily consent and authorize the following: Administration of homeopathic remedies, herbal and nutritional therapies, off label use of pharmaceuticals, injectable vitamins and amino acids.
I understand that no warranty or guarantee has been made regarding results of treatment. I realize that there may be risks and hazards related to the planned integrative treatment, including worsening of present symptoms, development of new symptoms (especially detox reactions) and undesirable interactions between various treatments, both conventional and alternative.
I have been given an opportunity to ask questions about the treatment of this health condition using conventional, integrative, and alternative methods. I have had an opportunity to discuss the possible risks and hazards of treatment and non-treatment and I believe that I have sufficient information to this informed consent. I certify this form has been fully explained to me, that I have read it (or have had it read to me), that the blank spaces have been filled in, and that I understand its contents. I also certify that 1 Stop Doc, LLC has provided this Disclosure and Consent Form to me and fully explained the diagnostic and treatment options available and has made no guarantees to me as to the success of this treatment. I acknowledge that 1 Stop Doc, LLC have informed me that they functions only as an educator and consultant, not as the primary care physician for any patient. I have assured her that I have another primary physician and do not/will not rely on 1 Stop Doc,LLC for that role.
ACKNOWLEDGEMENT
I hereby acknowledge that I have read and fully understand the treatment considerations and risks presented in this form. I also understand that there may be other problems that occur less frequently than those presented, and that actual results may differ from the anticipated results. I also acknowledge that I have discussed this form with the undersigned provider and have been given the opportunity to ask any questions. I have been asked to make a choice about my treatment. I hereby consent to the treatment proposed and authorize the provider indicated below to provide the treatment. I also authorize the provider to provide my health care information to my other health care providers , if deemed necessary.