Weight Loss Therapy Consent Form

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Full Name* This field is required.

First Name

Last Name

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Gender* This field is required.

Male

Female

Other

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Current Weight (in lbs)* This field is required.

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Target Weight (in lbs)* This field is required.

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Date of Birth* This field is required.

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Where Are You Located?* This field is required.

City

State

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Phone Number* This field is required.

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Email* This field is required.

example@example.com

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Weight Loss Therapy

GLP-1 receptor agonists such as Semaglutide, Tirzepatide, and Liraglutide are FDA-approved medications used to manage blood sugar and promote weight loss in eligible patients. This therapy is offered under medical supervision as part of a comprehensive wellness plan.

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Purpose of Treatment

GLP-1 medications are prescribed to reduce appetite, slow gastric emptying, enhance insulin sensitivity, and support long-term fat loss. They may also help regulate blood sugar in patients with insulin resistance or prediabetes.

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Kindly review the following and select any items that are applicable to your medical history or current health status.* This field is required.

I am at least 18 years old and not pregnant or planning to become pregnant.

I have no personal or family history of medullary thyroid carcinoma (MTC).

I have not been diagnosed with Multiple Endocrine Neoplasia syndrome type 2 (MEN2).

I do not have a history of pancreatitis or gallbladder disease.

I do not have gastroparesis or severe gastrointestinal motility issues.

I understand this medication may cause nausea, vomiting, or diarrhea, especially during the first few weeks.

I will inform my provider of any significant medical conditions or medication changes during treatment.

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I understand that a licensed medical provider will review my intake form and medical history to determine if this therapy is appropriate for me. No medication will be prescribed without clinical justification and professional medical judgment.

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Potential Risks and Side Effects

Common side effects include nausea, constipation, diarrhea, abdominal discomfort, headache, or fatigue. Serious but rare risks may include pancreatitis, kidney issues, allergic reactions, or gallbladder complications. The medication should be discontinued if you experience persistent severe abdominal pain, vision changes, or signs of dehydration.

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Monitoring and Follow-Up

I agree to participate in regular follow-up appointments as recommended by my provider. I understand that labs, vitals, and dosage adjustments may be required for safe and effective treatment.

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Please read and acknowledge the following disclosures to ensure informed consent and compliance with medical and legal standards.* This field is required.

I acknowledge that this treatment may include off-label or compounded formulations.

I consent to receive therapy via telehealth and understand that all evaluations and recommendations comply with state law.

I understand that Koreme Anti-aging & Aesthetics Group and its providers are not liable for adverse reactions due to undisclosed history, misuse, or noncompliance.

I understand that I may stop therapy at any time and that doing so will not affect my right to receive future care.

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Consent for Treatment

I have read and understand the above information. I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction. I voluntarily consent to the use of GLP-1 therapy under medical supervision.

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Signature* This field is required.Please sign below to confirm that the information provided is accurate and that you have read and understood the above acknowledgments.

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