Contraindications
Do NOT take GLP-1 medications (including Semaglutide or Tirzepatide) if you:
- Have a personal or family history of Medullar Thyroid Carcinoma (thyroid cancer).
- Have Multiple Endocrine Neoplasia Syndrome Type 2.
- Have a history of pancreatitis.
- Are pregnant, plan to become pregnant, or are breastfeeding.
- Are allergic to Semaglutide, Tirzepatide, BPC-157, or any other GLP-1 Agonist.
Medication Information
You may be prescribed Semaglutide or Tirzepatide as part of your treatment. These medications may be compounded and are not always the commercially branded versions. Dosing, administration, and response may vary. Your provider will determine the appropriate medication and dosage for your treatment plan.
Side Effects
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.
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 this prescription comes from a compounding pharmacy and is not FDA-approved. I have been informed that the manufacturing facility is FDA-monitored and the medication is third-party tested. I understand that these medications are not generic versions of the commercially available brand-name GLP-1s. 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 certify that I have read the contents of this form in its entirety. 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.