Informed Consent for Weight-Management Medications

 

I authorize PriorityYou Health Center,

Ila R. Mason FNP-C and her staff, to assist me in my weight-loss efforts.

PURPOSE OF TREATMENT AND GENERAL INFORMATION:

What is Compounded Semaglutide/Tirzepatide Weight Management Treatment: Compounded Semaglutide/Tirzepatide weight management injections are used for weight loss in conjunction with a diet and exercise plan. Compounded Semaglutide/Tirzepatide injections are delivered beneath the surface of the skin (subcutaneously) for chronic weight management in adults with obesity (BMI >30) or who are overweight (BMI >27) with at least one weight-related condition, including high blood pressure, diabetes type 2, and/or high cholesterol. Semaglutide/Tirzepatide mimics a glucagon-like peptide hormone called GLP-1, which slows the movement of food from the stomach into the small intestine, helping to reduce appetite and increase satiety after eating. Additional treatment benefits associated with Semaglutide/Tirzepatide weight management may include improved A1C and blood sugar levels by increasing insulin (a hormone that lowers blood sugar levels) and inhibiting glucagon (a hormone that raises blood sugar); improved blood pressure; reduced risk of major adverse cardiovascular events. What To Expect: There is no downtime associated with semaglutide/tirzepatide injections. Your treatment will begin with a consultation that includes blood work to check lab values and Ila Mason FNP-C will review your health and medication history to ensure you are a good candidate for semaglutide/tirzepatide injections. Multiple injections will be needed once weekly over the course of months to achieve desired results. Dosing adjustments will be titrated based on your body's response to tirzepatide and any side effects you're experiencing. Treatment: Typical treatment regimen includes an initial series of weekly injections, including monthly follow-ups. Your semglutide/tirzepatide injections (4 syringes) will be shipped to your home every month to inject yourself at home. If you do not feel comfortable injecting the medication on your own, you can also schedule a weekly follow up appointment. The appointment must be on the same day each week. While using semglutidfe/tirzepatide it is highly recommended that you: Eat a fibrous diet- focus on fruits and vegetables that are high in fiber. Eat small high protein meals as digestion is slowed down while on this medication. Avoid foods high in fat as they take longer to digest. Avoid spicy foods. Limit alcohol intake as this medication can lower blood pressure. Drink at least 32oz of water a day to avoid constipation.

POSSIBLE RISKS AND SIDE EFFECTS

Common side effects: nausea, vomiting, diarrhea, indigestion, abdominal pain, constipation, fatigue, and dizziness. The side effects usually subside after a few weeks of using the medication, but please call our office if any of these symptoms are severe or do not go away. This list is not exhaustive of all possible risks associated with tirzepatide weight management treatment, as there are both known- and unknown- side effects and risks associated with any

A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing. Report adverse side effects to your doctor or pharmacist. In the event of any emergency, call 911 immediately.

Semglutide/Tirzepatide injections are contraindicated in those who: are taking another GLP-1 receptor agonists such as rybelsus, bydureon, trulicity, or Victoza. are pregnant or are breastfeeding. have ever had Medullary Thyroid Cancer (MTC) (this includes a family history of MTC) have Multiple Endocrine Neoplasia Syndrome type 2 (MEN 2) have ever had a serious allergic reaction to semglutide/tirzepatide or any of the ingredients in semaglutide/tirzepatide, including compound formulations, which may include vitamin b12 and/or vitamin b6. Semaglutide/ Tirzepatide injections may not be suitable for you if you have any other medical conditions: plan to become pregnant (you should stop semglutide/tirzepatide 2 months prior to pregnancy) have, or have had, problems with your pancreas or kidneys. have type 1 diabetes, type 2 diabetes, or a history of diabetic retinopathy. are taking certain medications, including sulfonylureas or insulin. have, or have had, depression, mental health issues, and/or suicidal thoughts. In some situations, it may not be possible to achieve desired weight loss results. It is also possible that Semaglutide/Tirzepatide injections may fail to produce any reduction in weight. Should complications occur, additional- or other- treatments may be necessary. Semglutide/Tirzepatide is not a permanent solution for weight management and must be maintained with lifestyle and diet modifications; you may also require maintenance injections to maintain desired weight. As a weight management treatment, it is recommended to allow at least 90 days of treatment to achieve results. Duration of results is unknown and not guaranteed. By signing below, I acknowledge and agree: I have fully disclosed all medications, previous complications, planned or previous surgeries, sensitivities, allergies, or current conditions that may, or may not, affect my treatment. I have read the foregoing informed consent for Semaglutide/Tirzepatide Weight Management Treatment; I agree to the treatment and all known and unknown associated risks. I acknowledge that no guarantee has been given by anyone as to the results that may be obtained. In the event that I am not satisfied with my results, I agree not to seek a refund for treatment services rendered, as I am fully aware that there is no implied or explicit guarantee of results, as stated in the acknowledgement above. I understand- and agree- that all services rendered to me are charged directly to me and that I am personally responsible for payment. This treatment is not covered by insurance, and I am required to pay for all costs and medication out of pocket. I further agree in the event of non-payment and/or reversal of payment via a credit card dispute that I initiate, I will bear the cost of collection fees, and/or court fees, and/or any reasonable legal fees resulting from such instance.

I understand prices may vary and change. My charge will include my in-office follow-up appointments and medication. For women of childbearing age: by signing below I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of this treatment and that I am not breastfeeding. Furthermore, I agree to keep my treatment provider informed should I become pregnant during the course of this treatment. It has been explained to me in a way that I understand: There may be alternative procedures or methods or treatments. There are risks, known and unknown, to the procedure or treatment proposed. I have had ample opportunity to ask any questions regarding Semaglutide/Tirzepatide Weight Management Treatment benefits, side effects and after care, and all my questions have been answered to my satisfaction. I believe I have adequate knowledge to understand the nature and risk of the treatment to which I am consenting. By signing below, I am consenting to undergo this, and any subsequent Semaglutide/Tirzepatide Weight Management Treatment, with all aforementioned understood by me. I release the overseeing clinic physician, the person performing the Semaglutide/Tirzepatide Weight Management Treatment, Ila Mason FNP-C, and PriorityYou Health Center from liability associated with treatment.