GLP-1 or GLP-1&2 Weight Loss Therapy Informed Consent
Semaglutide is a human-based glucagon-like peptide-1 receptor agonist and Tirzepatide is a dual-acting agonist prescribed as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) that is considered outside a healthy range.
While using semaglutide/NAD or Tirzepatide/levocarnitine it is highly recommended that you:
- Eat a fiborous 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.
- Limit alcohol intake as this medication cna lower blood pressure.
- Drink atleast 32 oz of water a day to avoid constipation.
Do not take this medication if:
- You have a personal or family history of medullary thyroid carcinoma (Thyroid cancer).
- Multiple Endocrine Neoplasia syndrome type 2.
- You are pregnant or plan to become pregnant while taking this medication.
- You are diabetic and/or taking any medication related to lowering your blood sugar levels withoutspeaking with your endocrinologist.
- Specifically, if you are prescribed insulin because the combination may increase your risk ofhypoglycemia (low blood sugar) and dosage adjustments by your provider may be necessary.
- You have a history of pancreatitis.
- You are allergic to NAD, semaglutide or any other GLP-1 agonist such as: Adlyxin®, Byetta®, Bydureon®,Ozempic®, Rybeisus®, Trulicity®, Victoza® Wegovy®.
- If you have other allergies. This product may contain inactive ingredients, which can cause allergicreactions or other problems. Before using this medication, tell your provider your medical history.
Possible drug interactions:
- Anti-diabetic agents, specifically: insulin and sulfonylureas (e.g., lyburide, glipizide, imepiride, tolbutamide)due to the increased risk of hypoglycemia (low blood sugar). do not take this with other GLP-1 agonistmedications. Other medications used in diabetes, please tell your provider about any medications thatmay lower your blood sugar.
Possible side effects:
- Nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dyspepsia, dizziness,abdominal distention, belching, hypoglycemia, flatulence, gastroenteritis, and gastroesophageal refluxdisease. Subcutaneous injections: common injection site reactions characterized by itching, burning at thesite of administration with or without thickening of the skin (welting). If you notice other side effects notlisted above, contact your provider.
- A very serious reaction to this drug is rare. However, get medical help right away if you notice anysymptoms of a serious allergic reaction, including rash, itching/swelling (especially of theface/tongue/throat), severe dizziness, trouble breathing. Report adverse side effects to your provider. Inthe event of emergency, call 911 immediately.
IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THIS TREATMENT, OR ANY QUESTIONSWHATSOEVER CONCERNING THIS PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK THESTAFF NOW BEFORE SIGNING THIS CONSENT FORM.
By signing, I certify that I have read and understand the contents of this form. I am aware of the possibleside effects and drug interactions and give my consent for treatment. I have informed the medicatl staffof any known allergies to drugs or other substances, and any past adverse reactions I’ve experienced. Ihave informed the medical staff of all medications and supplements I’m currently taking. I understandthere are other ways and programs that can assist me in my desire to decrease my body weight andacknowledge that no guarantees have been made to me concerning my results.
Diagnosis codes:
- E66.9: Obesity
- Z71.3: Dietary counseling and surveillance
- Z68.XX: BMI code (fill based on weight and height)
HIPAA Authorization and Acknowledgement for Open Setting Communication with telehealth appointments
As a concierge medical spa operating in a home-based setting, we strive to provide a welcoming and comfortable atmosphere. Due to the nature of our space, some discussions regarding health, wellness, and treatment goals may occur in a shared or open area where others may be present.
To comply with the health insurance portability and accountability act of 1996 (HIPAA), and to respect you right to privacy, we ask you to review and acknowledge the following:
Acknowledgement of an open setting environment
I understand that:
- Consultations or conversations regarding weight goals, health history, treatment plans, vitamin injections, prescription therapies, IV therapy, toxin , and dermal filler may take place in an open area.
- Although reasonable efforts will be made to maintain confidentiality, there is a possibility that other clients or individuals may overhear portions of these conversations.
- I am not required to have any personal health discussions in an open setting.
- I understand that:
- Telehealth visits are not the same as face-to-face consultations and may limit the provider's ability to perform a complete physical exam.
- Technical failures (poor concentration, software issues) may delay or interrupt care.
- I may need to schedule an in-person exam or lab work to safely continue treatment
- Certain side effects or emergencies may require immediate in-person medical attention.
Client Rights
- I understand that I may change my preference at any time by informing a staff member.
- I understand that my choice will not affect my care or access to services in any way.