This document confirms informed consent for the use of compounded Semaglutide or Tirzepatide, prescription medication used for weight management.
Section A: Patient Informed Consent
I voluntarily consent to receive medical treatment, including the prescription of compounded Semaglutide or Tirzepatide, from Slimplexa.
I have disclosed all relevant personal medical information to my provider, including known allergies, current medications, medical conditions, and my social and family history.
I understand my right to be informed about alternative treatment options, potential side effects, and the associated risks and benefits.
I understand how Semaglutide or Tirzepatide works and its intended effects.
I have been instructed on the proper method of administering the medication.
I acknowledge that the medication will be dispensed from a compounding pharmacy, which is not FDA-approved. However, I have been informed that the pharmacy facility is monitored by the FDA and that third-party testing is conducted on the medication.
I understand that treatment costs may vary and that my charges will include time spent with my provider (both in-office and through other forms of communication), supplies, and the medication itself.
I understand that the provider may change the pharmacy used to fill prescriptions based on factors such as medication availability, shipping timelines, or cost. Any changes will be communicated to me.
I have been informed that improper use of this medication, or use without medical supervision, may be harmful.
I acknowledge that discontinuing the treatment may result in regaining the weight lost during the course of the program.
I understand that this medication may cause adverse effects. While not exhaustive, the following lists include the most common and serious reactions. I understand that side effects may be more pronounced when starting the medication or after dosage adjustments, and that, although rare, death is a possible risk.
Common Side Effects (not limited to):
Gastrointestinal: Nausea, vomiting, abdominal pain, diarrhea, constipation, indigestion, bloating, belching, flatulence, gastroenteritis, GERD, gastritis, increased lipase/amylase levels.
Neurological: Headache, dizziness.
Cardiac: Increased heart rate, hypotension.
Endocrine: Fatigue, hypoglycemia (especially in diabetic patients), alopecia.
Ophthalmic: Retinal disorders (especially in diabetic patients).
Dermatologic: Redness or pain at the injection site.
Serious Reactions (not limited to):
Thyroid C-cell tumors (observed in animal studies)
Medullary thyroid carcinoma
Hypersensitivity reactions, including anaphylaxis and angioedema
Acute kidney injury; exacerbation of chronic renal failure
Pancreatitis
Gallbladder disorders: Cholelithiasis, cholecystitis
Syncope
Section B: Patient Responsibilities
Prescription Use
I agree to obtain compounded Semaglutide or Tirzepatide only through my Provider.
If I intend to switch to a non-compounded version or pursue insurance coverage, I will inform my Provider in advance.
Medical History Disclosure
I will provide my complete and honest medical history to my Provider.
With my permission, my Provider may review additional medical records, labs, or imaging as needed.
I understand that this medication is contraindicated during pregnancy, and I will notify my Provider if I become pregnant or plan to conceive.
I will keep my Provider updated on any changes in health status, including new medications, allergies, surgeries, or family history.
My Provider may discuss my treatment plan with other healthcare professionals involved in my care.
I will disclose all medications I am taking to other healthcare providers.
Medication Administration
I will follow the Provider’s instructions exactly when using my medication.
I will not change my dosage without prior consultation.
I will store the medication as directed (refrigerated or frozen).
I will self-administer the medication subcutaneously once per week.
I will not share needles and will dispose of them safely.
I will seek guidance from my Provider if I have difficulty administering the injection.
I understand that the medication has a Beyond Use Date (BUD) and must be used within 12 weeks of dispensing.
Refills
All refills require a scheduled appointment.
I understand the importance of scheduling refill appointments in advance to avoid interruptions in treatment.
Refills are processed on Mondays.
I will not request early refills.
I may be asked to bring my medication to appointments for assessment of quantity and administration technique.
Safety
I will store the medication securely, away from children under 18.
I will not share or sell my medication to others.
Medication Adjustment
I agree to comply with any plan by my Provider to taper the medication or transition to a maintenance dose, if deemed appropriate.
Section C: Discontinuation of Treatment
I understand that my Provider may stop prescribing Semaglutide or Tirzepatide if:
I experience significant side effects or the treatment proves ineffective.
I provide false or incomplete medical or family history.
I do not comply with the Provider’s treatment plan.
I fail to adhere to the responsibilities outlined in this agreement.
Acknowledgment and Consent
I confirm that I have read and fully understood this form. All aspects of the treatment, including potential risks and benefits, have been explained to me. I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction. By signing below, I voluntarily consent to receive treatment with compounded Semaglutide or Tirzepatide as prescribed by my Provider.