GLP-1 Medication Waiver (Semaglutide and Tirzepatide)
I, acknowledge that I am voluntarily scheduling a consult for a GLP-1 receptor agonist medication, specifically semaglutide (e.g., Ozempic, Wegovy) or tirzepatide (e.g., Mounjaro, Zepbound), by East Coast IV, LLC for the purpose of medical weight loss or related health conditions. I will the opportunity to discuss the risks, benefits, and alternatives of this treatment with my healthcare provider and understand the following:
1. Common Side Effects
I understand that GLP-1 medications may cause side effects, which are generally mild to moderate and may decrease over time. These include, but are not limited to:
- Nausea, vomiting, or diarrhea
- Constipation or abdominal discomfort
- Decreased appetite
- Headache or fatigue
- Injection site reactions (e.g., redness, itching, or swelling)
I agree to report any severe or persistent side effects to my healthcare provider promptly.
2. Self-Injection Requirement
If I am taking the medication home or having it shipped to me, I am comfortable with self-injection or have arranged for assistance from a trained individual. I understand that improper administration may affect the medication’s effectiveness or safety.
3. Medication Sales Policy
I understand that all medication sales are final. Once the medication is dispensed, no refunds or exchanges will be provided, regardless of whether I choose to use it or experience side effects.
4. Diet, Exercise, and Alcohol
I understand that GLP-1 medications work best when combined with proper diet and regular exercise, as recommended by my healthcare provider. I am aware that alcohol should be avoided at all costs, as it can slow down weight loss progress and may interfere with the effectiveness of the treatment.
5. Laboratory Requirements
I understand that laboratory work may be required to be prescribed GLP-1 medications, at the discretion of my prescriber. If laboratory tests are ordered, I acknowledge that an additional fee will be required at the time of service.
6. Patient Responsibilities
I agree to:
- Follow my healthcare provider’s instructions for dosing, administration, diet, and exercise.
- Attend scheduled follow-up appointments to monitor my progress and health.
- Inform my provider of any changes in my health status, including new medications or conditions.
- Store the medication as instructed (e.g., refrigeration, away from children).
- Comply with any required laboratory testing as directed by my prescriber.
7. Voluntary Consent
I voluntarily consent to treatment with semaglutide or tirzepatide, understanding that no guarantees have been made regarding weight loss or other outcomes. I have had the opportunity to ask questions, and all my concerns have been addressed.
By signing below, I acknowledge that I have read, understood, and agree to the terms of this waiver.
Authorization for Use of Patient Information and/or Photographs/Video
At East Coast IV, LLC, we are dedicated to advancing healthcare through education, training, and community engagement. We deeply value the support of our patients who choose to share their experiences to help us fulfill this mission. Your privacy and the confidentiality of your medical information are our top priorities, and we will only use your information or images with your explicit permission. By acknowledging this form, you authorize East Coast IV, LLC and its affiliates to use your name, health-related information, photographs, videos, or interviews for purposes such as medical training, education, public relations, communications, or promotional activities. This may include publications, educational materials, social media, or other promotional content.
Important Information
Please note that once information, photographs, or videos are shared, East Coast IV, LLC cannot control how they may be used or shared by third parties. This authorization remains valid from the date of your signature until you withdraw it in writing. If you choose to withdraw your consent, we will discontinue using your information or images, but we cannot retract any disclosures made prior to your withdrawal. East Coast IV, LLC is not responsible for third-party use of previously disclosed materials. To withdraw your authorization, please send a written request to: East Coast IV, LLC 1200 Brass Mill Road, Suite B, Belcamp, MD 21017
HIPPA Statement
This HIPAA Privacy Notice applies to “Protected Health Information” or “PHI”. PHI is a subset of the personal information that we may collect from you when we submit a claim to your insurance provider so that they can reimburse us for the products or services that you are purchasing. Because PHI is regulated by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), we are required to provide you with this notice. This HIPAA Privacy Notice only covers your PHI and is incorporated as a portion of our complete Privacy Policy. In the event that there are any conflicts between our HIPAA Privacy Notice and our Privacy Policy, the terms of the HIPAA Privacy Notice will take priority if the subject is your PHI, and the Privacy Policy will control if the subject is any non-PHI information that we may collect from you. East Coast IV, LLC may use and disclose your PHI for many different reasons. PHI includes information that can be used to identify you that we have created or received about your past, present, or future health condition, such as a prescription. We must provide you with this notice about our privacy practices regarding use and disclosure of your PHI. With some exceptions, we may not use or disclose any more of your PHI than is necessary to accomplish the purpose of the use or disclosure. Below, we describe the different categories of uses and disclosure. Our Uses and Disclosures of your PHI:
• Help manage the health care treatment you receive
• Run our organization
• Pay for your health services
• Administer your health plan
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests and work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to
the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Your Rights:
HIPAA gives you certain rights related to your PHI. You may exercise any of these rights at any time by contacting us at info@EastCoastIV.com:
• Get a copy of your health and claims records
• Correct your health and claims records
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated
Your Choices:
For certain health information, you can tell us your choices about what we share. If you have a clear
preference for how we share your information in the situations described below, talk to us. Tell us whatyou want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in payment for your care
• Share information in a disaster relief situation
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when
needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
• Marketing purposes
• Sale of your information
Our Responsibilities
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of
your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice:
We can change the terms of this notice, and the changes will apply to all information we have about you.
The new notice will be available upon request, on our web site, and we will mail a copy to you.