I acknowledge that I am voluntarily entering into a medically managed weight loss program with JAENIX PLLC/Optimize by JaeNix.

I fully realize that entering any program involving weight reduction, which includes moderate calorie restriction, exercise, and medications, involves potential risks and side effects.

The risks include, but may not be limited to, the following:

1. Cardiovascular (heart or blood pressure): These problems may include heart palpitations, irregular beats, or rapid heartbeat. These effects are usually mild but can result in serious problems, including heart attack or stroke. Also, these medications may increase blood pressure, which if left untreated can lead to heart attack or stroke. If you discontinue the weight loss medication, the elevated blood pressure usually resolves. For this reason, if you are on blood pressure medications, you are required to monitor your blood pressure daily and discontinue medications if blood pressure rises, your heart rate increases, or you feel palpitations. 

2. Sudden Death: Patients with morbid obesity, particularly those with hypertension, heart disease, or diabetes, have a statistically higher chance of suffering sudden death when compared to normal weight people without such medical problems. Rare instances of sudden death have occurred while obese patients were undergoing medically supervised weight reduction, though no cause-and-effect relationship with the diet has been established. The possibility cannot be excluded that some undefined or unknown factor in the treatment program could increase this risk in an already medically vulnerable patient.

3. Reduced Potassium Levels: The calorie level you will be consuming is 800 or more calories per day, and it is important that you consume the calories prescribed in your diet to minimize side effects. Failure to consume all of the food and fluids, nutritional supplements, or taking a diuretic medication (water pill) may cause low blood potassium levels or deficiencies in other nutrients. Low potassium levels can cause serious heart irregularities. When someone has been on a reduced-calorie diet, a rapid increase in calorie intake, especially overeating or binge-eating, can be associated with bloating, fluid retention, disturbances in electrolytes, or gallbladder attacks and abdominal pain. For these reasons, following the diet carefully and gradually increasing calories after weight loss is essential.

4. Gall Bladder Disease: Any program resulting in rapid weight loss may precipitate the formation of gallstones, which could lead to cholecystitis (inflammation of your gallbladder), a medical urgency or emergency that could require surgery. This is typically due to rapid weight loss, not the medications you are taking. Symptoms include right upper abdominal pain, abdominal pain just below your ribs, nausea, and vomiting.

5. Pancreatitis: Pancreatitis, or an infection in the bile ducts, may be caused by gallstones or the development of sludge or obstruction in the bile ducts. Symptoms of pancreatitis include pain in the left upper abdominal area, nausea, and fever. Pancreatitis may be precipitated by binge-eating or consuming a large meal after a period of dieting. Long- term abuse of alcohol, the use of certain medications, and increased age may also be associated with pancreatitis. Pancreatitis may require surgery and may be associated with more serious complications and death. 

6. Psychiatric: There are reported cases of "hysterical or psychotic reactions" associated with the use or discontinuation of some of the drugs utilized for weight loss purposes. These reactions are extremely rare.

7. Men over 40 and post-menopausal women in general, and patients with risk factors for cardiovascular disease should have a cardiovascular evaluation before entering a medically managed weight loss program. This may include an ECG, a stress test, or other testing procedures, at the discretion of a cardiologist. If you are over the age of 40, post-menopausal (female), smoke, have a history of high blood pressure, high cholesterol, or you are diabetic, you acknowledge that you have had a cardiac evaluation and have been medically cleared prior to starting this weight loss program.

8. Common, but troublesome side effects may include, but are not limited to: dry mouth, palpitations, "speedy" feeling, headaches, sleeplessness, rash, fever, nausea, vomiting, allergic reactions, decreased insulin sensitivity, flushing, headache, fatigue, lightheadedness, abdominal cramping, joint pain, fluid retention, and additional side effects not listed that will be discussed during your evaluation with JESSICA BOGGS, APRN. These side effects are generally rare, and most patients tolerate treatment without issue. 

9. Drug interactions may occur if other medications are taken. Therefore, I will check with my prescribing medical provider before starting the program if I am taking other medications.

10. Certain medical conditions may be worsened if on this program including glaucoma, hypertension, and heart disease.

11. Pregnancy (Females Only): If you become pregnant, inform your physicianimmediately. Your diet must be changed promptly to avoid further weight loss, as a restricted diet could be damaging to a developing fetus. You must take precautions to avoid becoming pregnant during the course of weight loss.

12. The use of medications for weight management is indicated for those patients who have a BMI of 30 or higher or a BMI of 27 or higher with other medical conditions such as high blood pressure, diabetes, or high cholesterol. Prescribing medications for patients not fitting these criteria is considered "off label" and not "FDA approved". Therefore, the potential risks VS. benefits may be great. 

13. I understand that alcohol and illicit drug use is prohibited in the program. Drugs like cocaine and amphetamines, when used in conjunction with appetite suppressants and other medications prescribed, could cause serious injury or death. The use of alcohol will also affect your results. 

14. I understand that my daily caloric intake will be determined at my initial visit.

15. I acknowledge that weight loss varies from patient to patient and depends largely on motivation and commitment to diet and exercise. 

16. I hereby authorize JAENIX PLLC/Optimize by JaeNix, JESSICA BOGGS, APRN, and additional staff to evaluate and treat me for weight management. 

17. I understand that we offer compounded versions of semaglutide and tirzepatide, and if I prefer, my prescription can be sent to the pharmacy for the brand-name version. I acknowledge that I will be responsible for paying the monthly membership fee to the clinic and paying the pharmacy directly for the medication. JAENIX PLLC/Optimize by JaeNix does not accept insurance. I also attest that I do not have Medicaid/Medicare.

18. I have reviewed the risks and determined that the benefits outweigh the risks.

 

POTENTIAL SIDE EFFECTS

Common side effects may include:

Nausea, vomiting, constipation, or diarrhea
Headache or fatigue
Injection site redness or irritation
Reduced appetite, bloating, or burping

Rare but serious risks:

Pancreatitis
Gallbladder issues
Kidney problems from dehydration
Thyroid C-cell tumors (animal studies)
Hypoglycemia (especially when combined with other meds)

You should NOT take GLP-1 medications if you have:

Personal or family history of Medullary Thyroid Carcinoma (MTC)
Multiple Endocrine Neoplasia Syndrome type 2 (MEN 2)
Active gallbladder or pancreatic disease
Current pregnancy or breastfeeding

19. I understand that some treatment modalities may not be supported by scientific literature and may be considered experimental.

By signing this consent, you are enrolling in the Optimize by JaeNix Weight Loss Membership Program, which includes:

Access to your licensed provider for ongoing care and support
GLP-1 prescription management (Semaglutide or Tirzepatide)
Direct medication delivery from a licensed compounding pharmacy
Dose adjustments based on clinical response and tolerability
10% off all med spa services during your membership
A $75/month membership fee with a 3-month minimum commitment
Card must be kept on file. Medication costs are billed separately by the pharmacy.

 

GLP-1 TREATMENT DETAILS

GLP-1 receptor agonists like Semaglutide and Tirzepatide are used to:

Aid in weight loss by reducing appetite and delaying gastric emptying
Improve insulin sensitivity and glycemic control
Support treatment of PCOS, prediabetes, and metabolic conditions
Your treatment may involve titration of weekly dosing based on tolerance and effectiveness. You will be given detailed instructions for injection technique, side effect monitoring, and follow-up.

PATIENT RESPONSIBILITIES

I agree to report any side effects or concerns to my provider immediately.
I understand this medication is compounded and not FDA-approved for weight loss, though the active ingredients are approved for other uses.
I will follow up with labs or provider visits as recommended.
I understand my provider may recommend lifestyle changes to enhance results.
I agree to keep my card on file for monthly membership auto-pay and understand I may cancel with 7 days’ noticeafter completing the 3-month minimum.

ACKNOWLEDGEMENT & CONSENT

I understand the purpose, risks, and benefits of GLP-1 treatment and the membership model. I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction.

I voluntarily consent to participate in the weight loss membership and to receive treatment with compounded Semaglutide or Tirzepatide under the supervision of a licensed provider at Optimize by JaeNix.