COMPOUNDED GLP-1 MEDICATION PATIENT CONSENT FORM

TRANSFORMATIONS CENTER FOR WEIGHT LOSS COMPOUNDED
GLP-1 MEDICATION PATIENT CONSENT FORM
Name

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Date Of Birth:

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Purpose of this Consent:

You are being prescribed a compounded GLP-1 medication (e.g., semaglutide, tirzepatide, liraglutide) for weight management or treatment of metabolic conditions because of the following reason.

* Please select the statement that best describes your significant clinical difference.
Other Reasons:
Below are the potential risks, benefits, and responsibilities associated with its use.

What is Compounded GLP-1?

Compounded GLP-1 medications are custom-prepared versions of FDA-approved drugs created by
licensed compounding pharmacies. These formulations are not FDA-approved, but are made in compliance with state and federal regulations. They may include ingredients such as semaglutide or tirzepatide combined with other components such as vitamin b-12, vitamin b-6 or niacinamide.

Benefits
• Supports weight loss and metabolic health
• Improves insulin sensitivity
• Reduces appetite and cravings
• May improve markers like blood glucose and cholesterol

Risks and Side Effects

Common side effects include:
• Nausea, vomiting, or diarrhea
• Constipation or bloating
• Fatigue or dizziness
• Low blood sugar (especially with other diabetic medications)

Serious but rare risks:
• Pancreatitis
• Gallbladder issues
• Kidney problems
• Thyroid C-cell tumors (in animal studies)

Contraindications

You should not take compounded GLP-1 if you have:
• A personal or family history of medullary thyroid carcinoma (MTC)
• Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
• Severe gastrointestinal disease
• Known allergy to any of the components

Patient Responsibilities
• Follow the prescribed dosing schedule exactly
• Report any side effects immediately
• Attend follow-up appointments as recommended
• Inform your provider of any new medical conditions or medications

Alternative Options

You have been informed about alternatives, including:
• Lifestyle modifications (diet, exercise)
• FDA-approved GLP-1 medications
• Other prescription weight-loss therapies
Signature: Consent and Acknowledgment:

I understand that:

• Compounded GLP-1 medications are not FDA-approved.

• The safety and efficacy of compounded versions may vary.

• I have been informed of the risks, benefits, and alternatives. • I have had the opportunity to ask questions, and they have been answered to my satisfaction.
Date Signature GLP-1 Consent Form
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TRANSFORMATIONS CENTER FOR WEIGHT LOSS COMPOUNDED

GLP-1 MEDICATION PATIENT CONSENT FORM