Limited GLP-1 Program Informed Consent

Limited GLP-1 Program Informed Consent
Patient Name*

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1) Purpose & program

I am being evaluated for treatment with a GLP‑1/GIP medicine (tirzepatide; brand examples include Zepbound® for weight management and Mounjaro® for type 2 diabetes). Treatment is combined with nutrition, activity, and lifestyle changes. I understand what the medication is for, how it is given (once‑weekly subcutaneous injection), typical dose escalation, and expected duration. I may decline or stop at any time before the dose is given.

2) Alternatives

Alternatives include FDA‑approved GLP‑1/other weight‑management options as appropriate, lifestyle therapy alone, or no treatment. I may discuss these and ask questions.

3) Major risks & important warnings (summary)

• Boxed warning/contraindication: Do not use if I or a family member has medullary thyroid carcinoma (MTC) or MEN2. Report neck lump, hoarseness, trouble swallowing/breathing.

• Gastrointestinal effects (nausea, vomiting, diarrhea, constipation), sometimes severe; not recommended in severe GI disease/gastroparesis. Report persistent/worsening symptoms.

• Pancreatitis: sudden, severe abdominal pain with/without back pain—stop medication and seek care.

• Gallbladder disease: right‑upper abdominal pain, fever, jaundice—seek evaluation.

• Acute kidney injury from dehydration—maintain fluids; seek care for reduced urination or leg swelling.

• Hypoglycemia if combined with insulin or sulfonylureas—doses of those medicines may need to be lowered; know signs/symptoms.

• Suicidal thoughts/mood changes—report immediately; medication may be stopped.

• Oral meds & birth control: Delayed gastric emptying may affect oral drugs; monitor narrow‑therapeutic‑index meds. Oral hormonal contraceptives can be less reliable after starting or increasing dose—use a non‑oral method or add a barrier for 4 weeks after initiation and after each dose increase.

• Before anesthesia/deep sedation: Tell procedural clinicians I’m on a GLP‑1; rare aspiration events have been reported.

4) Pregnancy & special populations

Tirzepatide may cause fetal harm; I will stop if pregnant or planning pregnancy and will discuss breastfeeding. This therapy is for adults.

5) Medication sources & compounding policy

Our practice primarily uses FDA‑approved products. Compounded tirzepatide will only be considered when medically necessary and not essentially a copy of an FDA‑approved drug, with the patient‑specific clinical difference documented on my prescription (e.g., excipient allergy or a medically necessary nonstandard strength for micro‑dosing). Cost/insurance coverage alone is not a valid reason for a compounded copy. If a compounded product is used, I understand it is not FDA‑approved; while the pharmacy performs quality testing (e.g., potency and sterility), FDA has warned about fraudulent/unsafe GLP‑1 products and dosing errors with compounded versions. I will only use medications dispensed through clinic‑approved, state‑licensed 503A pharmacies or FDA‑registered 503B outsourcing facilities. Our clinic does not prescribe semaglutide.

6) Responsibilities

I agree to: (a) provide complete medical history, medication list, allergies, and requested labs; (b) attend scheduled follow‑ups; (c) follow the dose‑escalation plan exactly and never change dose or frequency without prescriber approval; (d) if using a vial, measure doses exactly as trained; store and handle pen/vial as labeled; (e) report adverse effects immediately, including severe abdominal pain; persistent vomiting/diarrhea/dehydration; signs of gallbladder disease; new neck mass/hoarseness; allergic reaction; very low blood sugar; markedly decreased urination/leg swelling; new/worsening depression or suicidal thoughts; (f) use fiber/hydration or other prescriber‑recommended measures to mitigate constipation, and report constipation lasting more than 5 days or severe GI symptoms for medical review.

7) Benefits & expectations

Benefits may include weight loss, improved metabolic markers, and symptom improvement when combined with diet and activity. Results vary, and no outcome is guaranteed. I understand potential costs, that aesthetic/weight‑management services are not refundable once provided, and that insurance coverage is not accepted.

8) Acknowledgments (mark yes)
I understand the major risks/precautions above. All my questions have been answered and I believe I have sufficient knowledge to make an informed choice.*

Yes
I was counseled on alternatives, including doing nothing, eating healthy and exercising.*

Yes
If a compounded product is used, it is not FDA‑approved; it will be used only when medically necessary and not essentially a copy of an FDA‑approved drug; cost alone is not sufficient.*

Yes
I will follow the dosing plan and measurement training; I understand dosing errors with compounded GLP‑1s have led to serious events.*

Yes
I received the Medication Guide/Instructions for Use and understand contraception advice if using oral birth control.*

Yes
I voluntarily consent to this treatment*

Yes
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Email*
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Reason for appointment*

Weight LossHormone TherapyNutritional TherapyPeptides
What is your current weight?*
How were you referred to this office?*

Emergency Contact & Insurance Info
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Who is your primary care doctor?*
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Primary Insurance:
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Patient Authorization for Delivery of Medications
I hereby authorize La Réserve Aesthetics staff to act on my behalf to accept medication delivery from an FDA licensed compounding pharmacy or the clinic’s dispensing physician and deliver my medications and refills to me as prescribed by my physician.

I understand that medications can be picked up at the clinic or mailed to my provided address on a weekly basis (or as often as ordered by the physician). This authorization will remain active for the course of my treatment at this clinic or until I revoke it in writing.

No Guarantee of Services
We do not guarantee that any services or medications will be provided to you until you have undergone the full initial sign up process and physician’s examination.

At the physician’s discretion only, you will be provided medications and/or services during your program at La Réserve Aesthetics.

Insurance Claims and Usage
I understand that if I use insurance for any lab-work or treatments that La Réserve Aesthetics. is not responsible for any portion insurance may not cover. I agree to contact my insurance company to check my out of network benefits prior to authorizing La Réserve Aesthetics. to use my health insurance.

No Refund Policy
La Réserve Aesthetics and all of its coinciding locations reserve the right to have a NO RETURN and NO REFUND policy.

If you need blood-work done via cash pay, the fee will be determined upon consultation. We are considered a specialty clinic and out of network for insurance. We are not responsible for any fees not covered by your insurance.
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This notice describes how information about you may be used and disclosed by La Réserve Aesthetics (the “Practice”) and how you can get access to this information. Please review it carefully. This Notice is effective August 20, 2019 and applies to all protected health information as defined by federal and state regulations. (Rev. 8/2019)

Understanding your health record/information:

What is in your healthcare record and how your protected health information (“PHI”) is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make better informed decisions when authorizing disclosure to others.

Each time you visit our office a record of your visit is made. This record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, referred to as your health or medical record, may be used by our Practice, as follows:

• A basis for planning your care and treatment

• A means of communication among the healthcare you professionals who contribute to your care. We may need to transmit PHI over an unsecured medium, such

• as a paper-to-paper fax. Unencrypted text messaging or e-mailing may be used when requested and/or initiated by you. Please note that transmitting PHI via an unencrypted medium presents a risk that your PHI could be read by a third party.

• Request a restriction on certain uses and disclosures of your information to health plans, if you paid for these services out of pocket

• Revoke your authorization to use or disclose healthninformation except to the extent that action has already been taken

Our Responsibilities. We are required to:

• Maintain the privacy of your health information as defined by federal/state laws

• Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you

• Notify you of a breach of your PHI

• Notify you if we are unable to agree to a requested restriction
We reserve the right to change our privacy practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will post the changes in our reception area and on our website. At your request, we will provide you a revised Notice of Privacy Practices.
I have answered all questions honestly and have read all information contained herein.*

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Limited GLP-1 Program Informed Consent

Patient Data

Emergency Contact & Insurance Info

Past Medical History

Systems Review

HIPAA Acknowledgement and Consent