Medical Weight Loss Program Consent Forms

Informed Consent for Medical Weight Loss Treatment

I understand that I am consenting to medical weight loss treatment under the care of a licensed Nurse Practitioner. This treatment may include:

Prescription weight loss medications (appetite suppressants, GLP-1 agonists, etc) Nutritional counseling and meal planning, Behavioral modification strategies Regular monitoring and follow-up appointments, Laboratory testing as indicated

I understand that weight loss medications may cause side effects including but notlimited to:

Common Side Effects:

Nausea, vomiting, diarrhea, constipation Headache, dizziness, fatigue Dry mouth, altered taste Sleep disturbances, mood changes, irritability

Serious but Rare Side Effects

Cardiovascular effects (increased heart rate, blood pressure changes) Psychiatric effects (depression, suicidal thoughts, anxiety) Gallbladder problems Kidney problems Pancreatitis (with GLP-1 medications) Allergic reactions Drug interactions with current medications

Contraindications

I understand that weight loss medications are contraindicated in certain conditions, and I have disclosed all relevant medical history. I understand that I should not take these medications if I:

Am pregnant, planning to become pregnant, or breastfeedingpate Have uncontrolled high blood pressure Have a history of heart disease, stroke, or arrhythmias Have a history of eating disorders Have hyperthyroidism Am taking certain medications (MAOIs, some antidepressants) Have a history of drug abuse Have severe kidney or liver disease.

Monitoring Requirements

I understand that I will need:

Regular follow-up appointments as scheduled Periodic vital sign checks (blood pressure, heart rate, weight) Laboratory monitoring as indicated (liver function, kidney function, glucose) Immediate reporting of any concerning symptoms Compliance with medication instructions and dosing

 Pregnancy Prevention

If I am a woman of childbearing age, I understand that:

I must use effective contraception while on weight loss medications. I must notify the provider immediately if I become pregnant. I must stop weight loss medications if pregnancy occurs. I will take a pregnancy test before starting treatment and periodically during treatment

Realistic Expectations

I understand that:

Weight loss results vary among individuals Typical weight loss is 5-15% of starting body weight over 3-6 months Weight loss may plateau or slow over time Lifestyle changes are essential for long-term success Weight regain may occur if medications are discontinued without lifestyle maintenance

INFORMED CONSENT ACKNOWLEDGMENT

I acknowledge that:

I have read and understand this consent form. All my questions have been answered satisfactorily I understand the risks, benefits, and alternatives to treatment. No guarantee of specific results has been made. I consent to the prescribed treatment plan.

For GLP-1 Receptor Agonists (Semaglutide, Liraglutide, etc:

I understand that I am being prescribed a GLP-1 receptor agonist and acknowledge: Mechanism of Action:

This medication slows gastric emptying and affects brain appetite centers to reduce hunger and promote satiety.

Administration

Given by subcutaneous injection Weekly/Daily Proper injection technique will be taught Injection sites should be rotated Medication requires refrigeration

Specific Risks

I understand the risk of pancreatitis and will report severe abdominal pain I understand the risk of gallbladder problems I understand the risk of kidney problems, especially with dehydration I understand the risk of diabetic retinopathy progression (if diabetic) I understand the risk of thyroid tumors (based on animal studies)

For Stimulant Medications (Phentermine, etc:)

I understand that I am being prescribed a stimulant medication and acknowledge: Mechanism of Action:

This medication affects brain chemicals to suppress appetite.

Specific Risks

I understand this medication can increase heart rate and blood pressure I understand this medication can cause insomnia and should be taken early in the day I understand this medication has potential for dependence I understand this medication can interact with many other drugs

Medication Compliance

Take medications exactly as prescribed

Not share medications with others

Not alter dosing without provider approval

Report all side effects promptly

Attend all scheduled follow-up appointments

Not take additional weight loss products without approval

Drug Interactions

I will inform all healthcare providers that I am taking weight loss medications and will not start any new medications, supplements, or herbal products without approval.

DISCONTINUATION I understand that these medications should notbe stopped abruptly and that gradual tapering may be necessary.