Informed Consent Form for Medical Weight Loss (Semaglutide and Tirzepatide)
Treatment Information:
Treatment: Medical Weight Loss with Semaglutide and Tirzepatide
Purpose of Treatment: To assist with weight loss and improve metabolic health through the use of medications Semaglutide and Tirzepatide.
Description of Procedure:
Semaglutide: This medication is a GLP-1 receptor agonist that helps regulate appetite and caloric intake. It is administered via subcutaneous injection once weekly.
Tirzepatide: This medication is a dual GLP-1 and GIP receptor agonist, also administered via subcutaneous injection once weekly. It works similarly to Semaglutide but targets two receptors to enhance weight loss and glucose control.
Potential Benefits:
Significant weight loss
Improved blood glucose control
Reduction in obesity-related conditions
Enhanced metabolic health
Improved quality of life
Support for overall wellness
Potential Risks and Side Effects:
Gastrointestinal issues (nausea, vomiting, diarrhea, constipation)
Hypoglycemia (especially if taken with other glucose-lowering medications)
Pancreatitis
Gallbladder problems
Kidney problems
Allergic reactions
Injection site reactions
Potential risk of thyroid C-cell tumors (as seen in animal studies)
Contraindications
Personal or family history of medullary thyroid carcinoma
Multiple endocrine neoplasia syndrome type 2
Severe gastrointestinal disease
Known hypersensitivity to any components of the medications
Alternative Treatments:
Lifestyle modifications (diet and exercise)
Other weight loss medications
Surgical interventions (bariatric surgery)
Behavioral therapy
Consent:
I understand the purpose, potential benefits, and risks of the medical weight loss treatment with Semaglutide and Tirzepatide.
I have had the opportunity to ask questions and discuss my concerns with my healthcare provider.
I understand that I can refuse or discontinue the treatment at any time.
I agree to follow the prescribed treatment plan, including dietary and exercise recommendations.
Acknowledgment:
I acknowledge that no guarantees have been made to me about the results of the treatment.
I consent to the use of Semaglutide and Tirzepatide for weight loss under the supervision of my healthcare provider.
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