Name *

First Name

Last Name

Phone

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I hereby confirm that I elect to take the semaglutide/Tirzepatide medication in accordance with my risk assessment and or lab work that are consistent with either diabetes mellitus, cardiovascular events, or abnormal BMI. *

I confirm

I understand that the clinical trials and studies on this medication are new, there are risks and benefits still being determined, and the research and its long term risks are not defined. *

I understand

I understand that based on current research while taking this medication I am at risk for the following Common reactions: experience nausea, diarrhea, vomiting, constipation, diabetic retinopathy, eructation, appetite decrease, hypoglycemia, dyspepsia, abdominal distension, GERD, flatulence, gastritis, amylase increase, lipase increase, injection site reaction. Severe reactions: thyroid c-cell tumor, medullary thyroid cancer, hypersensitivity reaction, anaphylaxis, angioedema, acute kidney injury, chronic renal failure exacerbation, pancreatitis, cholelithiasis, cholecystitis, ileus, syncope. *

I understand

I understand that there is no concrete evidence linking the effects of semaglutide with fertility including but not limited to: miscarriages, pregnancy efficacy duration, nursing. *

I understand

I understand that recent studies have proved semaglutide to affect the stimulation of collagen and thereby may increase the risk of collagen loss resulting in facial wrinkles and dropping. *

I understand

I confirm I am not nursing or pregnant. *

I confirm

I confirm that I do not have any history of thyroid cancer in my family. *

I confirm

I confirm that I have not had any previous adverse reactions to this medication or its constituents *

I confirm

I understand that once the provider sees it fit to terminate refills of this medication I will be tapered down and will no longer be prescribed this medication. *

I understand

I understand that the mechanism of this medication is to activate glucagon-like peptide 1 receptors, increasing insulin secretion, decreasing glucagon secretion and delaying gastric emptying. And consent to take it despite the risk of adverse effects it may be proved to have. *

I understand and Consent