Patient Consent Form for Special Compounded Semaglutide

Patient Consent Form for Special Compounded Semaglutide
Patient Name*

First NameLast Name
Date of Birth*

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Prescribing Provider: Danuta Kowalski

Clinic Name: Pure Medical Spa
Purpose
You are being prescribed compounded semaglutide for weight management. This form outlines the risks, benefits, and your consent to receive a medication that is prepared by a compounding pharmacy under Section 503A of the Federal Food, Drug, and Cosmetic Act.

What is Compounded Semaglutide?
Compounded semaglutide is not a commercially manufactured product (e.g., Wegovy or Ozempic). It is custom-prepared in a compounding pharmacy from raw active pharmaceutical ingredients (API) to meet your individualized dosing needs.
- Compounded medications are not FDA-approved.
- The quality and effectiveness may differ slightly from commercial brands.
- This medication is only available by prescription for a specific patient.
Patient has documented intolerance to standard dosing (e.g., nausea, GI side effects)Patient requires custom titration schedule (e.g., starting at 0.125 mg)Commercial products not tolerated or not appropriate for patient's medical profileOther
Risks & Considerations
- Nausea, vomiting, constipation, and other GI side effects may still occur.
- There may be variability in response due to differences in formulation.
- This medication is to be used only by you. Do not share or transfer to others.
- Notify your provider (call 312.312.7873) immediately if you experience side effects or worsening symptoms.
Alternatives
- Use of commercially available semaglutide medications (e.g., Wegovy, Ozempic)
- Lifestyle changes (nutrition, exercise)
- Other FDA-approved pharmacologic options for weight loss
I understand this is a compounded medication, not FDA-approved. - The reason my provider is recommending compounded semaglutide. - The potential risks and side effects. - I may choose not to receive this compounded medication and explore alternatives.I have had the opportunity to ask questions and all my concerns have been addressed. I consent to receive compounded semaglutide prepared by a 503A pharmacy.
Date of Signing the Consent*

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