Xpress Health Urgent care / Express Health Urgent care /Berkley Urgent Care Xpress Health Weight Loss Consent Form

I hereby give my informed consent to receive medical weight loss treatment, including semaglutide, tirzepatide, MIC/B12, glutathione, vitamin C,
glutamine, arginine, L-carnitine, and other wellness support injections, as recommended by the provider.
Semaglutide and tirzepatide are GLP-1 receptor agonist medications used as an adjunct to reduced calorie intake and increased physical activity for
chronic weight management.
While using semaglutide/tirzepatide, it is strongly recommended that you:
● Eat a fibrous diet rich in fruits and vegetables
● Eat small high-protein meals, as digestion may slow down
● Avoid foods high in fat
● Limit alcohol intake
● Drink at least 32 oz of water daily

Do NOT take this medication if:
● You have a personal or family history of medullary thyroid carcinoma (thyroid cancer)
● You have Multiple Endocrine Neoplasia syndrome type 2 (MEN2)
● You are pregnant, breastfeeding, or planning pregnancy
● You are diabetic and take blood sugar-lowering medications without first speaking with your endocrinologist or PCP
● You are prescribed insulin, as the combination may increase your risk of hypoglycemia and dosage adjustments may be necessary
● You have a history of pancreatitis, gallbladder disease, kidney disease, liver disease, or severe cardiac disease
● You are allergic to semaglutide, tirzepatide, or any other GLP-1 agonist medication
● You are currently taking any other GLP-1 medication or weight loss injection, including but not limited to Ozempic, Wegovy, Mounjaro,
Zepbound, Saxenda, Victoza, Trulicity, Rybelsus, Byetta, or any compounded semaglutide/tirzepatide from another source
Possible Side Effects
Possible side effects include nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dizziness, bloating, belching, reflux
symptoms, and injection-site reactions including itching, redness, burning, bruising, or swelling.
Serious allergic reactions are rare. Seek immediate medical attention for rash, swelling of the face or throat, severe dizziness, or trouble breathing.
Anti-diabetic agents, including insulin and sulfonylureas, may increase the risk of hypoglycemia. Please disclose all medications and supplements.

Laboratory Testing Recommendation / Patient Declination of Labs
I understand that baseline laboratory testing may be medically recommended prior to starting or continuing treatment in the Medical Weight Loss /
Wellness Program, including GLP-1 therapy with semaglutide or tirzepatide, to evaluate medication safety, screen for contraindications, and assess
underlying medical conditions.
If I choose to decline recommended laboratory testing, I acknowledge and agree to the following:
● I am voluntarily declining recommended laboratory testing prior to treatment initiation or continuation.
● I deny any known contraindications listed in this consent form.
● I understand the provider is relying on the accuracy and truthfulness of the medical history and medication information I provide.
● I accept full responsibility for following up with my primary care provider or specialist for routine health maintenance and lab monitoring.
● I understand it is my responsibility to complete routine laboratory testing at least yearly, or sooner if medically necessary, through my
PCP or specialist.
● I understand that starting or continuing treatment without labs may increase the risk of undetected medical conditions, side effects, or
complications.
● I release and hold harmless the clinic, provider, and staff from liability related to my decision to decline recommended laboratory testing.
● I understand the provider may require laboratory testing before future medication refills or dose increases.

Financial Responsibility / Self-Pay / No Refund Acknowledgment
I understand and acknowledge that this medical weight loss program is a strictly self-pay program and is not billed to insurance.
I understand that all services related to this program are non-covered and are my sole financial responsibility as out-of-pocket expenses, including
provider visits, medications, laboratory testing, supplies, wellness injections, and any other related treatment services.
I understand that all laboratory tests performed as part of this program are also self-pay and billed separately unless otherwise stated.
I understand that I am required to be seen by a provider at least once monthly at minimum to safely continue treatment, monitor progress, review side
effects, and make appropriate dose adjustments.
I understand and agree that all treatments, visits, medications, injections, laboratory services, supplies, and any other services or products provided as
part of this program are final and strictly non-refundable, including unused medication once dispensed.

I understand that this program offers two pricing tiers:
If I elect to take my medication home for self-administration, I may receive a discounted self-pay medication price.
If I later change my mind and request that the clinic’s provider or qualified medical team administer my injection in-office, I understand and agree that a
$25 administration fee per injection visit will apply in addition to the medication price and any other services provided.
I understand that changing from the discounted take-home option to in-office administration may result in additional charges.
Results Disclaimer
No guarantees or promises have been made regarding specific weight loss results. I understand that individual results vary based on adherence, diet,
physical activity, metabolism, and other medical factors.

Patient Acknowledgment
By signing below, I acknowledge that I understand the risks, contraindications, side effects, laboratory testing recommendations, my right to decline
laboratory testing, my responsibility for PCP follow-up and yearly labs, the self-pay structure, financial obligations, no-refund policy, and all other terms
associated with this program.