Med Spa Intake

I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of the staff responsible for any errors or omission that I may have made in the completion of this form.

This document is intended to serve as confirmation of informed consent for compounded Glucagon-like Peptide-1 (GLP-1) Injections (semaglutide, tirzepatide, or other), which are prescription medications used for weight loss.

DO NOT take this medication if you:

• Are under age 18 or have a BMI under 18.0
• Have severe renal/kidney impairment (eGFR <15) or severe hepatic/liver impairment
• Have a personal or family history of Medullary Thyroid Carcinoma or Multiple Endocrine Neoplasia Type 2
• Have a history of pancreatitis or severe stomach problems (i.e. gastroparesis)
• Are pregnant, plan to become pregnant, or are breastfeeding
• Are using concurrent treatment with any other products for weight management
• Are allergic to Semaglutide, Tirzepatide, BPC-157, or any other GLP-1 Agonist
• Have a history of suicide attempts or active suicidal ideation

Possible Side Effects: Nausea, Vomiting, Diarrhea, Constipation, Abdominal Pain, Headache, Fatigue, Dyspepsia, Dizziness, Abdominal Distention, Belching, Hypoglycemia, Flatulence, Gastroenteritis, Gastroesophageal Reflux Disease, Injection Site Reactions (itching or burning at site of administration with/without thickening of the skin)

A serious allergic reaction to this medication is rare. Seek medical attention if you experience symptoms such as rash, itching/swelling (especially of the throat), severe dizziness, or trouble breathing.

Drug Interactions: Compounded GLP-1s delay gastric emptying. May impact absorption of concomitantly administered oral medications. Use with caution.

Directions for use:

• I understand this medication must be injected in the subcutaneous tissues once weekly
• I understand this medication must be kept refrigerated
• I will notify my provider if I experience side effects or if I am having trouble with administration
• I will not share this medication (or needles) with others and agree to dispose of needles safely
• I understand this medication should be used in addition to lifestyle modifications, such as diet and exercise
  

PATIENT CONSENT:

I have informed my provider of all medical conditions, any known allergies to drugs or other substances, and any past adverse reactions I’ve experienced. I have informed my provider of all medication and supplements I am currently taking. I understand that I am being prescribed compounded GLP-1 medications, which are custom-prepared versions of FDA-approved drugs created by licensed compounding pharmacies. These formulations are not FDA-approved, but are made in compliance with federal regulations. They may include ingredients such as semaglutide or tirzepatide combined with other components such as vitamin B-12, Vitamin B-6 or niacinamide.

I understand that these medications are not generic versions of the commercially available brand named GLP-1s and Arctic Medical Center and Spa makes no claims for compounded products to be the equal, bioidentical, or generic versions of the commercially available brand name GLP-1s (Ozempic, Wegovy, Mounjaro, Zepbound, or other). I am aware of the possible side effects. I understand this medication could be harmful if taken inappropriately and should be used only as prescribed. I acknowledge that no guarantees have been made to me concerning my results.

I understand that it is not possible to predict all possible side effects or complications associated with using compounded GLP-1s. I understand the risks/benefits associated with tirzepatide/semaglutide and have received, read, and/or had explained to me any information pertaining to tirzepatide/semaglutide compound(s) I may be prescribed. I confirm that I am not pregnant nor breastfeeding and will not hold any Arctic Medical Center and Spa responsible for usage of this medication if pregnant or breastfeeding.

On behalf of myself, my dependents, and/or my personal representatives, I hereby release and hold harmless Arctic Medical Center and Spa, its staff, its compounding pharmacy used, and any of its subsidiaries from all liabilities or claims, whether known or unknown, arising out of, in connection with, or in any way related to the tirzepatide/semaglutide compound(s) I am prescribed.

I agree to be fully financially responsible for the full cost of the tirzepatide/semaglutide compound(s). I understand that payment is due prior to dispensing of the medication. I understand that the tirzepatide/semaglutide compound can take weeks to months to see noticeable effects (or may have no effect at all) and I will not be issued a refund for any reason whatsoever once I have agreed to these terms and have made payment.

I certify that I have read the contents of this form in its entirety. I understand how to use the medication. I have had the opportunity to ask questions and have had my questions answered. I fully understand the contents of this form and have no further questions. By signing this form, I voluntarily give my consent for treatment and agree to the risks.

I have read and agree to the terms above.