Consent (Individualized Medication Treatment)

We are committed to providing individualized care tailored to your unique health needs. As part of our treatment options, we are pleased to consider both FDA-approved, brand name medications and compounded alternatives. Our current evaluation considers:

FDA-Approved Brand Name Medications:

• Zepbound

• Mounjaro

• Ozempic

• Wegovy

Compounded Medications:
For patients who may benefit from a more specialized approach, we offer compounded formulations of semaglutide and tirzepatide. These compounded medications can be customized with alternative dosing schedules, alternative dosing frequencies, different routes of administration, and/or additives intended to help reduce side effects commonly seen with the brand name products.

Explanation of Compounded Medications:
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. This means that while they offer the advantage of customization, there may be differences in the consistency, efficacy, and safety profiles compared to those of the branded products.

Consent and Acknowledgment:
By proceeding with this treatment plan, you acknowledge that:

• 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. If you have any questions or need further clarification regarding your treatment options, do not hesitate to ask our healthcare team. Your health and well-being are our highest priorities, and we are here to support you in making the best-informed decision about your care.

Response options:

• I have read the above information and I do NOT wish to continue

• I have read and understand the above information and I do consent and wish to move forward with this treatment plan

Consent (GLP-1 and GIP/GLP-1)

Indication for Use
You are requesting treatment with a GIP/GLP-1 (Ozempic, Wegovy, or compounded semaglutide) or GIP/GLP-1 receptor agonist (Mounjaro, Zepbound, or compounded tirzepatide) medication as part of your treatment plan for the management of weight or obesity. These medications work by mimicking the action of incretin hormones, which help regulate blood sugar levels, promote feeling full, 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 may also cause side effects. Although not common, these medications can result in emergency room visits, hospitalizations, or even death. Common and serious side effects include, but are not limited to:

Common Side Effects:

• Nausea

• Vomiting

• Diarrhea

• Constipation

• Decreased appetite

• Indigestion

Serious Side Effects:

• Pancreatitis (inflammation of the pancreas)

• Hypoglycemia (low blood sugar), especially when used 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. If you experience severe abdominal pain, nausea, or vomiting, you should contact your healthcare provider immediately.

• Thyroid Tumors: Animal studies have shown an increased risk of thyroid tumors with certain GLP-1 medications. Although this has not been confirmed in humans, please inform your healthcare provider if you have a history of thyroid cancer.

• Hypoglycemia: When taken with other diabetes medications, particularly insulin or sulfonylureas, there is a risk of low blood sugar. It is important that your provider knows if any of these medications are added to your regimen.

• Kidney Function: This medication may affect kidney function, particularly in patients with existing kidney disease. Regular monitoring of kidney function may be required.

Monitoring and Follow-up
You will require regular follow-up visits to monitor your response to the medication and to assess for any side effects. We may intermittently ask for full-body selfie images to ensure that your reported weight is consistent.

Acknowledgment: 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.