Weight Management (Semaglutide/Tirzepatide) Prescription Drug Management Consent Southtowns Colon Hydrotherapy/Essential IV Therapy of OP This document is intended to serve as a confirmation of informed consent for compounded semaglutide, which is a prescription weight management medication.
A. Patient Informed Consent 1.I voluntarily request that MaryAnn Anderson, NP (provider) and the staff of Southtowns Colon Hydrotherapy, LLC, help me manage my weight loss needs, via Semaglutide/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 MaryAnn Anderson, NP 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 Angioedema Acute kidney injury Chronic renal failure exacerbation
Cholecystitis Syncope B. I understand that I have the following responsibilities: 1. I agree to obtain prescriptions for compounded semaglutide only from MaryAnn Anderson, NP. a. If I am looking to transition to a non-compounding pharmacy or seek insurance coverage, I will tell MaryAnn Anderson, NP in advance. 2. Medical history: I will tell MaryAnn Anderson, NP my complete medical history, including: allergies, medications, medical/surgical/social/family history.