I, the undersigned, hereby consent to receive weight loss injections that may include Semaglutide, Tirzepatide, and/or compounded versions of these medications, as prescribed by my healthcare provider. I understand that these medications are designed to help with weight loss, blood sugar control, and metabolic health. I acknowledge that I am fully informed that some of these medications are compounded, and they are not FDA-approved for the specific purpose of weight loss.

I Understand and Acknowledge the Following:

Treatment Plan:

The weight loss injections that I will receive may include Semaglutide (Wegovy, Ozempic), Tirzepatide (Mounjaro), and/or compounded versions of these medications.

I understand that Semaglutide and Tirzepatide are FDA-approved for treating type 2 diabetes, but not specifically FDA-approved for weight loss at this time. However, these medications have shown effectiveness in promoting weight loss in clinical studies and are prescribed off-label for weight management.

I am aware that compounded versions of these medications are not FDA-approved for weight loss and have been customized by licensed pharmacies to meet my specific needs. These compounded medications have not undergone the same rigorous FDA approval process as the commercial versions, and their safety and effectiveness may vary.

Compounded Medications and FDA Status:

The compounded versions of Semaglutide or Tirzepatide may be prescribed if the standard commercial versions are not available or suitable for my needs. These compounded medications are not FDA-approved for weight loss, and their quality, safety, and effectiveness have not been reviewed by the FDA.

I understand that compounded medications are prepared by licensed pharmacies based on a healthcare provider’s prescription and are tailored to my specific treatment plan. However, the lack of FDA approval means that these medications have not undergone the same clinical trials and rigorous evaluation required for commercially approved drugs.
I acknowledge that compounded medications may carry additional risks due to variations in manufacturing, dosages, and other factors, and I accept these risks as part of my treatment plan.

Possible Risks and Side Effects:

I understand that all medications, including Semaglutide, Tirzepatide, and compounded versions, carry risks of side effects. These may include, but are not limited to:

Common Side Effects: Nausea, vomiting, diarrhea, constipation, abdominal discomfort, headache, or fatigue.

Serious Side Effects: Pancreatitis, gallbladder issues, kidney problems, changes in blood pressure, allergic reactions, or thyroid issues.

Compounded Medications: Since compounded medications are not FDA-approved, I am aware that there is a higher risk of variability in quality, dosage, and consistency, and I accept these risks. If I experience any concerning side effects, I will notify my healthcare provider immediately.

Expected Results:

I understand that weight loss results vary from person to person and that there is no guarantee of specific weight loss or achievement of certain goals.

The effectiveness of Semaglutide and Tirzepatide may vary, and the compounded medications may also show varying results depending on how my body responds.

These medications are intended to help reduce body weight by regulating hunger, improving metabolism, and supporting healthy blood sugar levels, but results depend on my adherence to the prescribed treatment plan, including diet and exercise.

Monitoring and Follow-Up:

I agree to attend all scheduled follow-up appointments with my healthcare provider for monitoring my progress, adjusting the treatment plan, and assessing my overall health. I may be required to undergo lab tests, including but not limited to CBC, CMP, TSH, Lipid Panel, HbA1c, and other assessments to monitor the effects of the medication on my metabolism, thyroid function, kidney health, and overall well-being.

I will promptly report any side effects, discomfort, or changes in my health to my healthcare provider.

Contraindications and Disclosure:

I have provided a complete medical history to my healthcare provider, including any pre-existing medical conditions, medications, and allergies. I understand that some conditions (e.g., thyroid disease, history of pancreatitis, gallbladder disease) may make me unsuitable for this treatment.

I will immediately inform my healthcare provider if I become pregnant, plan to become pregnant, or begin breastfeeding during the course of treatment, as these medications may not be safe during pregnancy or breastfeeding.

I understand that I should not alter the prescribed dosage or treatment plan without consulting my healthcare provider.

Financial Responsibility:

I understand that I am responsible for all costs related to weight loss injections, including any office visits, laboratory tests, compounded medications, and other associated services.
I understand that my insurance may not cover the cost of compounded medications or weight loss injections, and I may be required to pay for these services out-of-pocket.

Voluntary Participation:

I understand that receiving these weight loss injections is entirely voluntary, and I can discontinue treatment at any time. However, I will notify my healthcare provider if I wish to stop the treatment to allow for an appropriate plan to be established.

Informed Consent:

I confirm that I have had the opportunity to ask questions about the medications being used, including the compounded versions of Semaglutide and Tirzepatide, their FDA approval status, and the potential risks and benefits of treatment.

I have received satisfactory answers to my questions and understand the risks and alternatives to this treatment, including the fact that other weight loss medications or lifestyle interventions may be appropriate.

I confirm that I have read and understood this consent form and voluntarily consent to participate in this weight loss program with compounded medications and FDA-approved treatments as outlined.