GLP-1 / GIP WEIGHT-LOSS MEDICATIONS
(Semaglutide, Tirzepatide, Retatrutide, and similar agents)

Purpose & How It Works: These medicines help regulate appetite, satiety, and blood glucose. They are used for chronic weight management and/or diabetes, together with diet, activity, and follow-up care.

Contraindications (do not use if any apply):

Personal or family history of medullary thyroid carcinoma (MTC) or MEN2.
Prior pancreatitis.
Pregnant, trying to conceive, or breastfeeding.
Severe gastroparesis or significant GI obstruction.
Allergy to the medication or its components.
Common Side Effects: Nausea; vomiting; diarrhea or constipation; abdominal pain; decreased appetite; reflux/heartburn; headache; fatigue; dizziness; injection-site reactions.

Serious Risks (seek care immediately if suspected):

Pancreatitis (severe, persistent upper abdominal pain ± vomiting).
Gallbladder disease (RUQ pain, fever, jaundice).
Acute kidney injury (dehydration, reduced urination).
Hypoglycemia, especially if using insulin/sulfonylureas (sweating, tremor, confusion).
Worsening diabetic retinopathy or vision changes when glucose improves rapidly.
Allergic reaction (hives, swelling, breathing difficulty).
Bowel obstruction or severe constipation.
Anesthesia risk (delayed gastric emptying increases aspiration risk—tell your surgeon/anesthesiologist).
Expectations & Monitoring: Results vary and are not guaranteed. Doses are titrated to balance benefit with tolerability. Labs, eye exams for diabetics, and clinical check-ins may be required. Do not share medication. Tell your provider about all other drugs (including insulin), alcohol use, and upcoming procedures.

Patient Acknowledgments:

I understand the benefits, risks, contraindications, and alternatives (diet, lifestyle, other meds, bariatric options).
I will stop the medication and contact the office/seek urgent care if severe side effects occur.
I will avoid use during pregnancy/breastfeeding and will inform my provider if I may be or become pregnant.
I consent to treatment with GLP-1/GIP medications as clinically indicated.

Acknowledgment and Consent I have read and understand the benefits, risks, responsibilities, and implications of GLP-1 peptide therapy. I acknowledge that no treatment guarantees specific results, and I voluntarily consent to receive this therapy as prescribed by my provider.

Non-Refund Policy Acknowledgment for GLP-1 Medications

By signing this informed consent, I understand and agree that all GLP-1 medications, including but not limited to semaglutide, tirzepatide, and retatrutide, are non-refundable once the medication has been ordered. This policy applies regardless of any side effects experienced, dissatisfaction with the medication, perceived lack of effectiveness, or a decision to discontinue use for any reason, including personal preference or change of mind.

I acknowledge that, for legal and safety reasons, these medications cannot be returned, reused, or resold once they have left the pharmacy or compounding facility. I accept full responsibility for the cost of the medication once the order has been placed on my behalf.

Please note: All medication sales are final—no refunds or returns—as prescriptions are custom-compounded specifically for each patient.

PEPTIDE &/OR NAD+ THERAPY INFORMED CONSENT
Purpose & Status: Peptides (e.g., CJC/Ipamorelin, MOTS-c, AOD-9604, BPC-157, etc.) and NAD+ may be prescribed off-label. They are not FDA-approved for anti-aging/performance/weight-loss indications. Potential benefits may include support for cellular health, energy, recovery, sleep, joint/tendon comfort, or body composition.

Risks/Side Effects: Injection-site reactions; flushing; headache; fatigue/somnolence or insomnia; nausea; appetite or mood changes; water retention/edema; changes in blood pressure or glucose; palpitations; dizziness; unknown long-term risks. Some peptides are contraindicated with active malignancy or recent cancer history without specialist clearance; not advised during pregnancy/breastfeeding.

Patient Acknowledgments:

I understand the off-label nature and that results are not guaranteed.
I will follow dosing instructions and report adverse effects promptly.
I will disclose all medications/supplements and medical history.
☑ I have read and understand the Peptide/NAD+ Informed Consent.

CHIROPRACTIC TREATMENT INFORMED CONSENT

Proposed Care: Evaluation and treatment may include spinal/extremity manipulation (adjustments), mobilization, soft-tissue therapies, traction/decompression, therapeutic exercise, and physiotherapeutic modalities (e.g., heat/ice, e-stim, ultrasound), as clinically indicated.

Benefits: Pain relief; improved mobility/posture/function; reduced muscle tension; enhanced daily activities and wellbeing.

Common Reactions: Temporary soreness, stiffness, headache, fatigue.

Uncommon/Rare Risks: Sprain/strain; rib or other fracture; disc herniation or aggravation; stroke associated with cervical manipulation (very rare); nerve irritation; burns/skin irritation from modalities; short-term symptom increase.

Patient Acknowledgments:

I understand risks/benefits/alternatives (including no treatment or referral).
I will immediately report worsening symptoms, new neurologic deficits, or unusual reactions.
I may refuse or withdraw consent at any time.
Chiropractic care is not emergency care; for emergencies I will call 911.
☑ I consent to chiropractic examination and treatment as recommended.

Innovative Health & Wellness LLC

Agreement Concerning Charges for Chiropractic / Medical Services

This agreement is made between (1) Innovative Health and Wellness LLC ("IHW") and (2) the undersigned patient of IHW ("Patient") and the undersigned attorney for the patient ("Attorney").

Patient has requested that IHW extend credit to Patient for chiropractic / medical services while Patient seeks insurance benefits and / or recoveries for damages and injuries, which gave rise to a need for IHW services. Attorney has undertaken to represent Patient in connection with claims for insurance benefits and / or damages or injuries; and Attorney has requested that IHW provide Attorney with general information regarding chiropractic / medical care; and Attorney has requested that IHW provide Attorney with copies of medical records and bills, and that IHW waive ordinary photocopy charges for the same. Charges shall apply for preparation of a narrative report, if Attorney request one. Patient also requested that IHW provide Attorney with the foregoing, and has authorized release to Attorney of records and information appertaining to Patient's condition and chiropractic / medical services rendered by IHW (including without limitation, case history, diagnosis, treatment, progress notes, etc.) IHW is willing to meet Patient's and Attorney's request upon the terms and conditions described below.

IHW shall extend credit to Patient for chiropractic / medical services. Payment shall be due upon the occurrence of the first of the following events: (a) payment by any insurance company or third party to or on behalf of Patient, in connection with Patient's claims for insurance benefits and / or for damages and injuries for which IHW service were provided; (b) discontinuation by Patient of reasonable collection efforts (as determined solely by IHW) against such insurance companies or third parties; (c) violation of this agreement by Patient or Attorney; or (d) expiration of 18 (eighteen months), following execution of this Agreement. (e) If the patient terminates treatment on his or her own all monies owed will be due immediately. The parties expressly understand that the obligation to pay IHW's charges is not contingent upon recovery of insurance benefits or claims proceeds.
Upon each receipt by Attorney of such insurance benefits or claims proceeds Attorney shall pay directly to IHW the then outstanding balance owed to IHW (up to the amount of benefits or proceeds received). Patient hereby instructs Attorney to pay IHW directly from the proceeds, and Patient agrees not to revoke this instruction before IHW is paid in full. Patient also agrees to make the same instruction to any associated or successor Attorney who may represent Patient regarding the same.
Patient assigns to IHW the proceeds received by patient or on Patient's behalf up to the then outstanding balance owed to IHW; the parties agree that this assignment is irrevocable. The parties agree that this is an assignment coupled with an interest of insurance proceed and / or anticipated claim recoveries, and is not an assignment of Patient's right to pursue claims against third parties.
So long as Patient and Attorney comply with the terms herein, no interest shall accrue upon the debt owed IHW. In the event on non-compliance by either Patient or Attorney then interest shall accrue upon charges, from original dates of services rendered, at the rate on one and one half percent per month until paid. In the event Patient or Attorney violate the terms of this Agreement, IHW shall be entitled to recover all cost if collection including 15% attorney's fees. In the event of a good-faith dispute by patient of the charges owed to IHW, Patient and Attorney agree to identify such dispute promptly upon their review of the charges, and Patient and Attorney agree that the amount of IHW charges that is not in dispute shall be paid to IHW, and the entire remaining balance of dispute shall be paid to IHW, charges shall be retained by Attorney in Attorney's trust or escrow account pending resolution of the dispute, or shall be interpleaded in a court of competent jurisdiction. The parties agree that in no event shall any compromise or accommodation of IHW charges be valid unless in writing signed by Dr. David M. Orlando D.C.. In the event of a dispute regarding charges due to IHW, the parties agree to use good faith efforts to try to resolve the dispute before resort to litigation, and to consider equally sharing the cost to engage a professional mediator to facilitate resolution attempts.

☑ I agree to the authorization/assignment above.