Patient Admission and Consent Form

Patient or Legal Guardian Signature:

I, the undersigned, have read and understood the information provided on this form. I willingly consent to the following specified medical treatments and procedures.

Informed Consent for Vitamin B-12, Vitamin B-6, and GLP-1 / GIP Therapy (Including Compounded Medications)

This Informed Consent (the "Consent") applies to treatment provided by SLIMCARE SAN ANTONIO WEIGHT LOSS AND MEDICAL CLINIC (the "Clinic") and governs the administration and prescribing of Vitamin B-12, Vitamin B-6 (pyridoxine), GLP-1 receptor agonists, and dual GLP-1/GIP receptor agonists, whether FDA-approved or compounded. This Consent applies to services rendered in the states of Texas, California, and Nevada.

1. Description of Therapies
Vitamin B-12 and Vitamin B-6 are essential vitamins that support energy metabolism, nerve function, red blood cell formation, and overall metabolic health. GLP-1 (glucagon-like peptide-1) receptor agonists and dual GLP-1/GIP (glucose-dependent insulinotropic polypeptide) receptor agonists affect appetite regulation, gastric emptying, insulin secretion, and glucose metabolism. Semaglutide is a GLP-1 receptor agonist. Tirzepatide is a dual GLP-1 and GIP receptor agonist.

2. Off-Label Use Disclosure
I understand that the use of Vitamin B-12, Vitamin B-6, semaglutide, tirzepatide, and/or combination or compounded formulations for energy, weight management, metabolic support, or wellness purposes may constitute off-label use. Off-label prescribing is legally permitted in Texas, California, and Nevada when based on a licensed provider’s clinical judgment. No guarantees of outcomes have been made.

3. Compounded Medication Disclosure (503A / 503B)
I understand that some medications prescribed or administered may be compounded and are not FDA-approved. Compounded medications are prepared in accordance with the Federal Food, Drug, and Cosmetic Act.

503A compounding pharmacies prepare patient-specific prescriptions pursuant to a valid prescription for an identified individual and are primarily regulated by state boards of pharmacy.

503B outsourcing facilities may compound medications in larger batches, are registered with the U.S. Food and Drug Administration, and comply with current Good Manufacturing Practices (cGMP).

I acknowledge that compounded medications may differ from FDA-approved products in strength, excipients, stability, absorption, and bioavailability.

4. Combination Compounds
I understand that medications may be prescribed individually or compounded in combination, including but not limited to semaglutide or tirzepatide combined with Vitamin B-6 (pyridoxine), for purposes such as individualized dosing or tolerability. I acknowledge that compounded combination products have not been reviewed or approved by the FDA for safety or efficacy.

5. Risks and Potential Side Effects
All medications and supplements carry potential risks. Common side effects of Vitamin B-12 and Vitamin B-6 may include injection site discomfort, mild gastrointestinal upset, headache, dizziness, flushing, or fatigue. Rare but serious risks may include allergic reactions or, with prolonged excessive Vitamin B-6 exposure, nerve-related symptoms such as numbness or tingling.

Potential side effects of GLP-1 and/or GIP receptor agonists may include nausea, vomiting, diarrhea, constipation, abdominal discomfort, bloating, decreased appetite, reflux, dizziness, fatigue, and injection-site reactions. Less common but serious risks may include hypoglycemia (especially when used with other glucose-lowering agents), gallbladder disease, pancreatitis, kidney injury related to dehydration, and severe allergic reactions.

6. Contraindications and Medical History Disclosure
I agree to inform the Clinic if I have or have had any of the following: Leber’s Disease, liver disease, kidney disease, iron deficiency, folic acid deficiency, neurological disorders, pancreatitis, gallbladder disease, severe gastrointestinal disorders, medullary thyroid carcinoma (MTC), Multiple Endocrine Neoplasia syndrome type 2 (MEN-2), or if I am pregnant, breastfeeding, or planning to become pregnant. I also agree to disclose all medications, supplements, and known allergies.

7. Patient Responsibilities
I agree to follow prescribed dosing instructions, attend recommended follow-up visits, and promptly report any side effects or adverse reactions. I will not alter dosing or frequency without provider approval and will seek immediate medical attention for severe or concerning symptoms.

8. No Guarantee of Results
I understand that individual responses vary and that no specific outcomes, including weight loss, increased energy, or metabolic improvement, are guaranteed.

9. Consent and Release of Liability
By initialing below, I acknowledge that I have read and understand this Informed Consent and have had the opportunity to ask questions. I voluntarily consent to treatment with Vitamin B-12, Vitamin B-6, GLP-1 receptor agonists, and/or dual GLP-1/GIP receptor agonists, whether FDA-approved or compounded, including combination products. To the fullest extent permitted by law in Texas, California, and Nevada, I release and hold harmless SLIMCARE SAN ANTONIO WEIGHT LOSS AND MEDICAL CLINIC, its providers, employees, and agents from liability arising from treatment, except in cases of gross negligence, willful misconduct, or violations of applicable law.

INVESTIGATIONAL MEDICATION DISCLOSURE (ORFORGLIPRON ONLY)
This section only applies exclusively to patients who elect to receive Orforglipron.

I understand that Orforglipron is an investigational medication currently undergoing clinical evaluation. It may not yet be fully approved by the U.S. Food and Drug Administration (FDA) for general commercial use for weight management and/or other indications.

I acknowledge that this disclosure applies only to Orforglipron and does not apply to other medications that may be offered through this program. Other medications available through this provider may be FDA-approved for their indicated uses.

If I choose to receive Orforglipron, I understand:

The medication is considered investigational.
Long-term safety and efficacy data may still be developing.
Clinical trial results do not guarantee individual outcomes.
Alternative FDA-approved options have been made available and/or discussed.
If I do not select Orforglipron, this section does not apply to my treatment.

By initialing below, I confirm that I understand the investigational status of Orforglipron and voluntarily elect to proceed with this specific medication.

SEMAGLUTIDE & TIRZEPATIDE (GLP-1 / GIP) INJECTIONS INFORMED CONSENT

I give my consent to receive semaglutide and/or tirzepatide injections as prescribed by my healthcare provider at SLIMCARE SAN ANTONIO MEDICAL WEIGHT LOSS AND WELLNESS (the "Clinic"). This informed consent applies to treatment provided in the states of Texas, California, and Nevada.

Semaglutide is a glucagon-like peptide-1 (GLP-1) receptor agonist. Tirzepatide is a dual GLP-1 and glucose-dependent insulinotropic polypeptide (GIP) receptor agonist. These medications may be prescribed for FDA-approved indications or for off-label use, including weight management and metabolic support, when deemed medically appropriate by a licensed provider. I have been informed of the proper method of administration, dosing schedule, and storage requirements.

Contraindications and Medical History
I understand that I should not take semaglutide or tirzepatide if I have, or fail to disclose, any of the following conditions:

Pregnancy, breastfeeding, or plans to conceive while using this medication
Personal or family history of Medullary Thyroid Carcinoma (MTC)
Multiple Endocrine Neoplasia Syndrome Type 2 (MEN-2)
History of pancreatitis, gallbladder disease, kidney disease or failure, liver disease or failure, or severe gastrointestinal disorders
Known allergy or hypersensitivity to semaglutide, tirzepatide, or other GLP-1 receptor agonists (including but not limited to Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy®)
Diabetes with retinopathy or concurrent use of glucose-lowering medications without appropriate medical supervision
Potential Side Effects
I understand that possible side effects may include, but are not limited to: nausea, vomiting, diarrhea, constipation, abdominal pain or discomfort, bloating, dyspepsia, belching, gastroesophageal reflux, headache, fatigue, dizziness, injection site reactions (including itching, burning, redness, swelling, or skin thickening), and decreased appetite.

Less common but potentially serious risks include hypoglycemia (particularly when used with insulin or sulfonylureas), gallbladder disease, pancreatitis, dehydration-related kidney injury, and severe allergic reactions. Symptoms of serious allergic reactions may include rash, hives, swelling of the face, lips, tongue, or throat, difficulty breathing, or anaphylaxis, which require immediate medical attention.

Drug Interactions
I understand that semaglutide and tirzepatide may interact with other medications, particularly insulin and sulfonylureas, increasing the risk of hypoglycemia. I agree not to use other GLP-1 receptor agonists concurrently unless specifically directed by my provider and to inform the Clinic of all medications, supplements, and over-the-counter products I am using.

Compounded Medication Disclosure (503A / 503B)
I understand that my medication may be an FDA-approved product or a compounded medication that is not FDA-approved. Compounded medications are prepared in accordance with the Federal Food, Drug, and Cosmetic Act.

503A compounding pharmacies prepare patient-specific medications pursuant to a valid prescription for an identified individual and are primarily regulated by state boards of pharmacy.

503B outsourcing facilities compound medications in larger batches, are registered with the U.S. Food and Drug Administration, and comply with current Good Manufacturing Practices (cGMP).

I acknowledge that compounded medications may differ from FDA-approved products in concentration, excipients, stability, absorption, and bioavailability.

Treatment Responsibilities
I acknowledge that semaglutide and/or tirzepatide therapy is one component of a comprehensive treatment plan that may include nutrition, physical activity, and lifestyle modifications. I understand that regular follow-up visits and dose adjustments may be necessary and agree to comply with all recommended monitoring and instructions.

California-Specific Disclosures and Acknowledgments
I acknowledge that California law provides specific patient protections and that nothing in this Consent waives rights that cannot be waived under applicable law. I understand that this Consent is not a contract of adhesion and that I am free to decline or discontinue treatment at any time. I further acknowledge that I have been advised of reasonable alternatives to treatment, including lifestyle modification alone and FDA-approved commercially manufactured medications, and that I have had the opportunity to ask questions regarding risks, benefits, and alternatives.

I acknowledge that compounded medications, if used, are not FDA-approved and that variability in compounded products may exist. I understand that clinical outcomes cannot be guaranteed and that adverse effects may occur even when medications are used appropriately.

Patient Acknowledgment and Consent
I confirm that I have provided complete and accurate medical information and understand that it is my responsibility to notify the Clinic of any changes to my medical history, medications, or health status. I acknowledge that no specific results or outcomes have been guaranteed.

By initialing below, I confirm that I have been informed of the material risks, benefits, and reasonable alternatives associated with semaglutide and/or tirzepatide therapy. I have had the opportunity to ask questions, and all questions have been answered to my satisfaction. To the fullest extent permitted by law in Texas, California, and Nevada, I voluntarily consent to treatment. I understand that this Consent does not release the Clinic or its providers from liability for professional negligence, fraud, or unlawful acts, but does apply to known and unknown risks inherent in treatment when provided consistent with the applicable standard of care.

Medication Change or Transition Acknowledgment (Semaglutide ↔ Tirzepatide)
If my treatment plan is changed from semaglutide to tirzepatide, or from tirzepatide to semaglutide, I acknowledge that:

• The medications are pharmacologically distinct and may differ in potency, dosing, side effect profile, and response
• Dose titration, temporary interruption, or re-initiation may be required for safety
• Prior tolerance of one medication does not guarantee tolerance of the other
• New or different side effects may occur following a medication change

I acknowledge that the medication transition has been explained to me, that I have had the opportunity to ask questions, and that I consent to the medication change as recommended by my provider.

SHIPMENT, BILLING, PRESCRIPTION & NO-REFUND AGREEMENT
I understand and agree to the following terms:

1. No Subscription or Recurring Billing
This program does not operate on an automatic shipment, subscription, or recurring billing model.
Each order is initiated by me individually.
My payment method is charged per order at the time I authorize purchase.
There are no automatic refills and no automatic future charges.

2. Payment Authorization & Order Processing
By submitting payment, I authorize the provider to immediately initiate prescription processing.
Orders are typically reviewed and transmitted to the pharmacy within the same business day after payment confirmation.
Once payment has been processed, the medical service has begun.
I understand that due to the immediate nature of prescription processing, cancellation requests may not be possible once payment is completed.

3. Prescription Issuance Constitutes Services Rendered
I understand and agree that:

Medical review, clinical evaluation, and prescription authorization constitute professional medical services.
Once a prescription has been issued and/or transmitted to the pharmacy, medical services are considered rendered.
Professional services are non-refundable once performed, regardless of whether medication has been shipped or received.

4. Limited Prescription Validity
Prescriptions issued through this program are limited in quantity and duration.
Prescriptions are typically valid for one fill and may include no more than one refill, subject to provider discretion.
Future refills require medical reassessment and new authorization.

5. Pharmacy & Fulfillment Separation
I acknowledge that:

The prescribing provider and the dispensing pharmacy are separate entities.
The pharmacy is responsible for compounding, dispensing, labeling, and shipping medication.
The provider is not responsible for pharmacy processing timelines, compounding procedures, shipping carrier delays, or delivery errors outside the provider’s direct control.
Any concerns regarding damaged shipments or delivery issues must be addressed in accordance with pharmacy and carrier policies.

6. No-Refund & Final Sale Policy
I understand and agree:

Once medication has been prescribed, processed, compounded, dispensed, or shipped, it is non-returnable and non-refundable.
All sales are final.
Change of mind, perceived lack of effectiveness, failure to tolerate medication, missed doses, improper administration, delay in starting treatment, or personal financial circumstances do not qualify for refunds.
Regulatory restrictions prohibit the return or resale of prescription medications once dispensed.

7. Shipping & Carrier Delays
Shipping timelines are estimates and not guarantees.
Delays caused by carriers, weather, holidays, or events outside the provider’s control do not constitute grounds for refund, reversal, or cancellation.
Risk of transit delays does not invalidate this agreement.

8. Chargeback & Payment Dispute Policy
I agree that:

I will not initiate a chargeback for services rendered or medication dispensed in accordance with this signed agreement.
Initiating a chargeback after prescription issuance, pharmacy processing, or shipment constitutes a breach of this agreement.
The provider may formally dispute any chargeback using this signed consent as proof of authorization and services rendered.
I may be responsible for any administrative fees, merchant processing penalties, collection costs, or legal fees incurred as a result of improper payment disputes, to the extent permitted by law.

9. Voluntary Acknowledgment
By initialing below, I confirm that:

I have read and understand this agreement in full.
I understand that prescription medications cannot be returned once dispensed.
I understand that payment authorizes immediate medical service and prescription processing.
I voluntarily agree to these terms.

Indemnification Clause

I agree to indemnify, defend, protect, and hold harmless the medical providers employed by SLIMCARE SAN ANTONIO MEDICAL WEIGHT LOSS AND WELLNESS CLINIC, and their respective officers, directors, employees, stockholders, assigns, successors, and affiliates ("Indemnified Parties"), from and against any and all liabilities, losses, claims, damages, judgments, settlement payments, deficiencies, penalties, fines, interest, and costs or expenses suffered, sustained, incurred, or paid by the Indemnified Parties in connection with, resulting from, or arising out of, directly or indirectly:

The rendering of medical care, services, advice, and/or treatment by the medical providers employed by SLIMCARE SAN ANTONIO MEDICAL WEIGHT LOSS AND WELLNESS CLINIC;
My failure to disclose all relevant information regarding my medical history, physical condition, medications, supplements, or allergies;
Acts or omissions by me that impact the delivery or effectiveness of care;
Any harm, injury, or adverse events resulting from medical care, pharmaceuticals, or compounded medications provided directly or indirectly by the medical providers employed by SLIMCARE SAN ANTONIO MEDICAL WEIGHT LOSS AND WELLNESS CLINIC, including but not limited to semaglutide (GLP-1) or tirzepatide (GLP-1/GIP) injections, with or without Vitamin B-6 or Vitamin B-12 or other compounded formulations.
I acknowledge that I am aware of the potential side effects, risks, and complications associated with these medications and treatments, including those that are off-label or compounded, and I accept all such risks. I agree that I will not seek indemnification or damages from the Indemnified Parties for any such outcomes except in cases of gross negligence, willful misconduct, or violations of applicable law in Texas, California, or Nevada.