Treatment Consent

Weight loss medications are traditionally prescribed for individuals with a BMI of 30 or higher, or for those who are overweight (BMI 25-29) with a related health condition. Using these medications for someone in the 25–29 BMI range without another health condition is considered "off-label" use. This means the medication is being prescribed in a way not specifically approved by the U.S. Food and Drug Administration (FDA). Please follow your prescribed regimen closely and report any side effects or concerns.

It is not safe to take these medications while pregnant or breastfeeding. The FDA advises that these medications may pose a risk to a developing fetus. Oral contraceptives alone may not be effective, as the medication can reduce their effectiveness. The FDA specifically recommends continuing oral contraception alongside a barrier method (like condoms) for the first month after starting a weight loss medication and for the first month after any dose increase. Alternatively, you can switch to a non-oral contraceptive method (such as an IUD or implant) before beginning the medication. After stopping the medication, you should continue using a backup method, such as condoms, for two months to ensure the medication has fully cleared your system before trying to conceive. Additionally, its safety during breastfeeding is unknown, so if you are nursing, consult your doctor to explore safer weight loss options.

We are committed to providing individualized care that considers your unique health needs and preferences. Your treatment plan may include either FDA-approved, brand-name medications or compounded alternatives, depending on what is most appropriate for your situation.

FDA-Approved Brand Name Medications:

• Zepbound
• Mounjaro
• Ozempic
• Wegovy

Compounded Medications:

For patients who may benefit from a more specialized approach, we may recommend compounded formulations of semaglutide and tirzepatide. These customized medications can offer:

• Alternative dosing schedules
• Alternative dosing frequencies
• Different routes of administration

Compounded medications are custom-prepared by licensed pharmacists to better meet an individual patient's specific needs. Unlike FDA-approved brand name products, compounded medications are not subject to the same rigorous testing and extensive clinical trials. While this customization can be an advantage, there may be differences in the consistency, efficacy, and safety profiles compared to those of the branded products.

You acknowledge and understand:

• You have been informed of the available treatment options, including both FDA-approved brand name medications and compounded alternatives.
• You understand that compounded medications are tailored to meet individual needs but are not subjected to the same level of testing as brand name products.
• Your treatment plan will be determined based on your candidacy and specific health requirements, ensuring the most appropriate therapy for you.

Please review this information carefully and ask any questions you may have. Your health and well-being are our priorities.

Please attest to the following confirming that all information you have provided to us is true and complete.

Consent: I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.

Indication for Use:

You are requesting evaluation and treatment with GLP-1 (Ozempic, Wegovy, or compounded semaglutide) or GIP/GLP-1 receptor agonist (Mounjaro, Zepbound, or compounded tirzepatide) for weight or obesity management. These medications work by mimicking incretin hormones that help regulate blood sugar, promote feelings of fullness, and reduce food intake.

Potential Benefits:

• Weight loss or weight management
• Improved blood glucose control
• Reduced cardiovascular risk
• Potential improvement in overall metabolic health

Potential Side Effects:

While these medications can be beneficial, they can also cause side effects, including emergency room visits, hospitalizations, or even death.

Common Side Effects:

• Nausea
• Vomiting
• Diarrhea
• Constipation
• Decreased appetite
• Indigestion

Serious Side Effects:

• Pancreatitis (inflammation of the pancreas)
• Hypoglycemia (low blood sugar, especially with other diabetes medications)
• Gallbladder disease (e.g., gallstones)
• Kidney problems
• Allergic reactions (e.g., rash, itching, swelling)
• Gastroparesis (paralysis of the bowels)

Risks and Considerations:

Pancreatitis:

There is a risk of developing pancreatitis while taking these medications. Contact your healthcare provider immediately if you experience severe abdominal pain, nausea, or vomiting.

Thyroid Tumors:

Animal studies have shown an increased risk of thyroid tumors with certain GLP-1 medications. This risk has not been confirmed in humans. Please inform your healthcare provider if you have a history of thyroid cancer.

Hypoglycemia:

These medications can cause low blood sugar, especially when taken with other diabetes medications (insulin or sulfonylureas). It is important that your provider knows about all medications you are taking.

Kidney Function:

These medications may affect kidney function, especially in patients with existing kidney disease. Regular monitoring may be required.

Monitoring and Follow-up:

• Regular follow-up visits to monitor your response and assess for side effects
• Intermittent requests for full-body selfie images to ensure reported weight consistency

Acknowledgement and Consent:

I acknowledge the potential benefits, risks, and side effects of GLP-1 or GIP/GLP-1 receptor agonist medications. I understand the importance of regular monitoring and follow-up appointments. I consent to the use of GLP-1 or GIP/GLP-1 receptor agonist medications as part of my treatment plan for overweight or obesity.