Mounjaro (Tirzepatide) Consent Form
1. Purpose of Treatment
I understand that Mounjaro (
tirzepatide
) is a prescription medication used for the management of
type 2 diabetes
and may also be prescribed for
weight management
when clinically appropriate.
2. How the Medication Works
I understand that Mounjaro works by affecting hormones involved in blood sugar control and appetite regulation.
3. Potential Benefits
I understand that potential benefits may include improved blood sugar control and, in some cases, weight reduction. Actual results vary from person to person.
4. Possible Risks and Side Effects
I understand that Mounjaro can cause side effects. These may include nausea, vomiting, diarrhoea, reduced appetite, or abdominal discomfort. I understand that more serious side effects are possible, and any concerning symptoms should be discussed with a healthcare professional promptly.
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5. Treatment Requirements
I understand that:
This medication must be used exactly as prescribed.
Regular follow-up with my healthcare professional is important.
I should inform my clinician about any other medications or medical conditions.
6. Pregnancy and Breastfeeding
I understand that Mounjaro may not be suitable during pregnancy or breastfeeding, and I should discuss family-planning considerations with my clinician.
7. Patient Responsibilities
I agree to:
Use the medication only as directed.
Report any side effects or concerns.
Attend follow-up appointments as advised.
8. Consent
I have had the opportunity to ask questions about Mounjaro and understand the information provided. I consent to starting or continuing treatment with Mounjaro as discussed with my healthcare professional.
Patient Name:
Date of Birth:
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Address:
Email Address:
example@example.com
Phone:
Format: 00000000000.
Patient Signature:
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Date:
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
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