Tirzepatide Injection - Client Consent & Responsibility Agreement
Please review each section and complete all required fields to acknowledge your consent and responsibility regarding Compounded Tirzepatide.
Compounded Tirzepatide
Client Full Name
*
Email
*
example@example.com
Date
*
-
Month
-
Day
Year
Date
Contact Number
*
Please enter a valid phone number.
Format: (0000-0000000).
I confirm that I am voluntarily purchasing and choosing to use Tirzepatide injection. I acknowledge that my decision to use this product is made under my own discretion.
Medical Clearance & Laboratory Responsibility
*
The seller may request medical clearance and/or laboratory results prior to purchase.
If I proceed without submitting medical clearance or tests, I am doing so at my own risk.
Risks & Possible Side Effects
*
Nausea
Diarrhea
Constipation
Vomiting
Results are not guaranteed.
STOP / Assumption of Risk
*
I take full responsibility for my decision.
I will not hold the seller liable for any adverse effects or outcomes from my own choice.
I have disclosed my medical history & current health conditions.
*
I have disclosed my medical history & current health conditions.
I have read and understood the above agreement. I fully accept responsibility for my decision.
*
I have read and understood the above agreement. I fully accept responsibility for my decision.
Client Signature
*
Printed Name
*
Date
*
-
Month
-
Day
Year
Date
Submit Consent
Submit Consent
Should be Empty: