GLP-1 Therapy Consent Form
Review the risks, expectations, and care model before signing your informed consent.
GLP-1 Therapy Consent Form — The Menopause Clinic.
GLP-1 receptor agonists (such as semaglutide or tirzepatide) are effective for weight management but carry real risks that require your informed understanding before starting. This consent outlines those risks, what's expected of you during treatment, and what to expect from our care model. By signing below, I confirm that I have read and understand the following.
Risks I Understand
FDA Warning. In animal studies, this class of medication (which includes semaglutide and tirzepatide) caused a type of thyroid tumor called C-cell tumors, including a rare thyroid cancer called medullary thyroid carcinoma, or MTC. It is not known whether this happens in humans — no confirmed cases have been reported in people taking this medication — but because the risk can't be ruled out, we don't prescribe it to anyone with a personal or family history of MTC, or a genetic condition called Multiple Endocrine Neoplasia syndrome type 2 (MEN 2), which raises the risk of this cancer. This is exactly why we screen for that history before prescribing, and why it's the first thing on this list.
I understand the risk of pancreatitis, and that if I develop severe or persistent abdominal pain, I will go to the nearest emergency room or call 911 right away — I will not wait to hear back from my care team first. I will message my care team afterward so we can follow up.
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I understand
I have read and understand the FDA warning above.
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I understand
I confirm I have been screened and do not have a personal or family history of MTC or MEN 2, as explained above.
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I understand
I understand this medication increases my risk of gallstones and gallbladder disease.
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I understand
If I have diabetic retinopathy, I understand rapid blood sugar improvement on this medication can worsen it, and I will report any vision changes immediately.
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I understand
I understand that severe GI side effects, including vomiting and diarrhea, can lead to dehydration and, in rare cases, acute kidney injury, and I will contact my care team if I cannot keep fluids down.
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I understand
If I am on insulin or a sulfonylurea, I understand my risk of low blood sugar increases and my care team may need to adjust those medications.
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I understand
Not applicable
I understand I should report any new or worsening depression, anxiety, or thoughts of self-harm to my care team right away.
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I understand
I understand I must inform any anesthesia provider or surgical team that I am taking a GLP-1 medication before any procedure requiring sedation or anesthesia, due to delayed stomach emptying.
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I understand
I understand nausea, vomiting, diarrhea, and constipation are common side effects, especially during dose increases, and usually improve over time.
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I understand
I understand the pregnancy guidance for this medication, including stopping it at least 2 months before a planned pregnancy, and I confirm the statement that applies to me.
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I am not pregnant
I am not planning pregnancy in the next year
I am not breastfeeding
I have discussed my situation with my provider
I understand The Menopause Clinic will not be adjusting my blood pressure, blood sugar, or other non-GLP-1 medications as part of this program, and I will keep my primary care provider or prescribing doctor updated so they can make any needed adjustments independently.
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I understand
What's Expected of Me
I understand GLP-1 medication must be used with a reduced-calorie diet and increased physical activity, and not as a stand-alone treatment.
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Yes, I understand
I understand treatment may be long-term and stopping the medication typically leads to weight regain.
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Yes, I understand
I will log my weight weekly using the short GLP-1 Weekly Weigh-In form, and complete the fuller GLP-1 Check-In every 4 weeks during titration and quarterly after my efficacy checkpoint.
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Yes, I agree
I will contact the clinic promptly if I have concerning symptoms rather than waiting for my next scheduled Weekly Weigh-In or Check-In.
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Yes, I agree
I understand I must attend the efficacy checkpoint visit 3 months after my dose has stabilized, and that titration typically takes 4–5 months.
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I understand
Our Care Model
I acknowledge that GLP-1 Support is a separate add-on from my perimenopause/menopause membership.
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I acknowledge
I understand the program pricing is $75/month through my efficacy checkpoint, dropping to $50/month after that visit, in addition to my membership, with no cost to be evaluated for eligibility.
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I understand
Initial visit format
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Video visit (included)
In-person visit (+$50)
I understand ongoing monitoring is through the symptom tracker and secure messaging between visits, not scheduled appointments.
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I understand
I acknowledge that the required efficacy checkpoint visit and any additional visits for side effects or lack of response may be scheduled as needed.
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I acknowledge
I confirm I am physically located in the state of Louisiana for all interactions with The Menopause Clinic, including messaging, telehealth visits, and check-ins.
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I confirm
I understand that medication and any labs are billed separately through the manufacturer's self-pay program and standard lab billing, and that my provider determined eligibility after reviewing the Pre-Treatment Questionnaire before this program began.
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I understand
Signature
Full Name
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First Name
Last Name
Date of Consent
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Month
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Day
Year
Date
Signature
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Submit Consent
Submit Consent
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