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Consent Form - GLP-1 Products Semaglutide and Tirzepatide (Wegovy®, Ozempic®, Rybelsus®, Zepbound®, Mounjaro®)

Z Medi Clinics & Z Medi Spa Consent Form for GLP-1 Products (Wegovy®, Ozempic®, Rybelsus®, Zepbound®, Mounjaro®)

Overview and Purpose of Treatment

At Z Medi Clinics and Z Medi Spa, we offer prescription treatment options that include FDA-approved GLP-1 receptor agonist medications for appropriate patients. These medications include:

Semaglutide-based Treatments

  • Wegovy®: FDA-approved for weight loss

  • Ozempic®: FDA-approved for type 2 diabetes

  • Rybelsus®: FDA-approved for type 2 diabetes

Tirzepatide-based Treatments

  • Zepbound®: FDA-approved for weight loss

  • Mounjaro®: FDA-approved for type 2 diabetes

These medications may support weight loss, improve insulin sensitivity, and assist in managing blood sugar levels in patients with type 2 diabetes. They are prescribed for adults with:

  • Overweight  and obesity

  • Overweight  with 

    • Type 2 diabetes (T2DM)

    • High blood pressure (hypertension)

    • High cholesterol (hyperlipidemia)

Important: These medications are not indicated for type 1 diabetes mellitus (T1DM) or diabetic ketoacidosis. They are intended for individuals with type 2 diabetes mellitus (T2DM) or those without diabetes who meet weight-related criteria.

They are intended to be used alongside a reduced-calorie meal plan and increased physical activity as part of a medically supervised wellness program.

Important Safety Information

These medications are not for everyone. You should NOT take these medications if:

  • You or a family member has ever had medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)

  • You have had a serious allergic reaction to semaglutide, tirzepatide, or any of their ingredients

Potential Risks and Side Effects

GLP-1 medications may cause serious side effects, including:

  • Thyroid tumors or thyroid cancer: Notify your provider of any neck lumps, hoarseness, difficulty swallowing, or shortness of breath.

  • Pancreatitis: Severe stomach pain that may radiate to your back, with or without vomiting.

  • Gallbladder disease: Pain in upper abdomen, yellowing of skin/eyes, fever, or light-colored stools.

  • Kidney injury: Especially with dehydration from vomiting or diarrhea.

  • Vision changes (particularly in individuals with diabetes)

  • Increased heart rate or palpitations

  • Severe allergic reactions: Swelling, difficulty breathing, rash, dizziness

  • Low blood sugar (hypoglycemia) especially when combined with insulin or sulfonylureas

  • Mental health changes, including depression or suicidal thoughts

Common side effects include:

  • Nausea, vomiting, diarrhea, constipation

  • Headache, fatigue, dizziness

  • Bloating, gas, heartburn

Pregnancy & Breastfeeding

  • These medications should not be taken during pregnancy.

  • If you plan to become pregnant, discontinue at least 2 months before conception.

  • Safety during breastfeeding is unknown; use is not recommended.

Use and Administration

  • Administered via subcutaneous injection, usually weekly.

  • Take injections on the same day each week, ideally in the evening to minimize gastrointestinal side effects.

  • Do not share injection pens or needles.

Medication Interactions

Tell your provider about all medications and supplements, including:

  • Diabetes medications (especially insulin or sulfonylureas)

  • Herbal supplements or weight loss aids

  • Over-the-counter medications

GLP-1 medications slow gastric emptying and may affect how other oral medications are absorbed.

Provider Information

  • You will be evaluated and treated by a licensed physician and mid level providers like physician assistant (PA), and or nurse practitioner (NP) that all direct supervision of licensed physicians

    All care is delivered under Texas medical regulations.

Acknowledgment and Informed Consent

By signing below, I acknowledge that:

  • I have received verbal and/or written information about GLP-1 medications, including purpose, benefits, and risks.

  • I understand that results may vary and are dependent on multiple factors including adherence, diet, and exercise.

  • I have had the opportunity to ask questions, which were answered to my satisfaction.

  • I will only use these medications under supervision of a licensed provider.

  • I have disclosed all relevant medical history and medications to my provider.

Signature & Consent

I confirm that I fully understand this information, and I consent to treatment with GLP-1 medications under the supervision of Z Medi Clinics/Z Medi Spa.

I HAVE READ AND FULLY UNDERSTAND THIS CONSENT FORM AND I REALIZE I SHOULD NOT SIGN THIS FORM IF ALL ITEMS HAVE NOT BEEN SATISFACTORY EXPLAINED TO ME. WITH MY SIGNATURE I ACKNOWLEDGE THAT MY QUESTIONS HAVE BEEN ANSWERED FULLY, AND THAT I HAVE BEEN REQUESTED TO READ THIS FORM AND HAVE BEEN GIVEN AMPLE TIME TO UNDERSTAND ALL ITS CONTENTS.

Z Medi Clinics and Z Medi Spa

Disclamier: At Z Med Clinics  we are NOT prescribing the Brand name Semaglutide BUT we are prescribing the generic compounded (Semaglutide) injection which is an injectable prescription medicine used for adults with obesity (BMI ≥30) or overweight (excess weight) (BMI ≥27) who also have weight-related medical problems to help them lose weight and keep the weight off.

  • Semaglutide should be used with a reduced calorie meal plan and increased physical activity.
  • Semaglutide contains semaglutide and should not be used with other semaglutide-containing products or other GLP-1 receptor agonist medicines.
  • It is not known if Semaglutideis safe and effective when taken with other prescription, over-the-counter, or herbal weight loss products.
  • It is not known if Semaglutide can be used safely in people with a history of pancreatitis.
  • It is not known if Semaglutide is safe and effective for use in children under 18 years of age.

Semaglutide may cause serious side effects, including:

  • Possible thyroid tumors, including cancer. Tell your healthcare provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. In studies with rodents, Semaglutide and medicines that work like Semaglutide caused thyroid tumors, including thyroid cancer. It is not known if Semaglutide will cause thyroid tumors or a type of thyroid cancer called medullary thyroid carcinoma (MTC) in people.
  • Do not use Semaglutide if you or any of your family have ever had a type of thyroid cancer called medullary thyroid carcinoma (MTC) or if you have an endocrine system condition called Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).

Do not use Semaglutide if:

  • you or any of your family have ever had a type of thyroid cancer called medullary thyroid carcinoma (MTC) or if you have an endocrine system condition called Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
  • you have had a serious allergic reaction to Semaglutide or any of the ingredients in Semaglutide.

Before using Semaglutide, tell your healthcare provider if you have any other medical conditions, including if you:

  • have or have had problems with your pancreas or kidneys.
  • have history of diabetic retinopathy.
  • have or have had depression, suicidal thoughts, or mental health issues.
  • are pregnant or plan to become pregnant. Semaglutide may harm your unborn baby. You should stop using Semaglutide 2 months before you plan to become pregnant.
  • are breastfeeding or plan to breastfeed. It is not known if Semaglutide passes into your breast milk.

Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Semaglutide may affect the way some medicines work and some medicines may affect the way Semaglutide works. Tell your healthcare provider if you are taking other medicines to treat diabetes, including Sulfonylureas or insulin. Semaglutide slows stomach emptying and can affect medicines that need to pass through the stomach quickly.

What are the possible side effects of Semaglutide?

Semaglutide may cause serious side effects, including:

  • inflammation of your pancreas (pancreatitis). Stop using Semaglutide and call your healthcare provider right away if you have severe pain in your stomach area (abdomen) that will not go away, with or without vomiting. You may feel the pain from your abdomen to your back.
  • gallbladder problems.Semaglutide may cause gallbladder problems, including gallstones. Some gallstones may need surgery. Call your healthcare provider if you have symptoms, such as pain in your upper stomach (abdomen), fever, yellowing of the skin or eyes (jaundice), or clay-colored stools.
  • increased risk of low blood sugar (hypoglycemia) in patients with type 2 diabetes, especially those who also take medicines for type 2 diabetes such as sulfonylureas or insulin. This can be both a serious and common side effect. Talk to your healthcare provider about how to recognize and treat low blood sugar and check your blood sugar before you start and while you take Semaglutide. Signs and symptoms of low blood sugar may include dizziness or light-headedness, blurred vision, anxiety, irritability or mood changes, sweating, slurred  speech, hunger, confusion or drowsiness, shakiness, weakness, headache, fast heartbeat, or feeling jittery.
  • kidney problems (kidney failure). In people who have kidney problems, diarrhea, nausea, and vomiting may cause a loss of fluids (dehydration) which may cause kidney problems to get worse. It is important for you to drink fluids to help reduce your chance of dehydration.
  • serious allergic reactions. Stop using Semaglutide and get medical help right away, if you have any symptoms of a serious allergic reaction, including swelling of your face, lips, tongue, or throat; problems breathing or swallowing; severe rash or itching; fainting or feeling dizzy; or very rapid heartbeat.
  • change in vision in patients with type 2 diabetes. Tell your healthcare provider if you have changes in vision during treatment with Semaglutide.
  • increased heart rate. Semaglutide can increase your heart rate while you are at rest. Tell your healthcare provider if you feel your heart racing or pounding in your chest and it lasts for several minutes.
  • depression or thoughts of suicide. You should pay attention to any mental changes, especially sudden changes in your mood, behaviors, thoughts, or feelings. Call your healthcare provider right away if you have any mental changes that are new, worse or worry you.

The most common side effects of Semaglutide may include: nausea, diarrhea, vomiting, constipation, stomach (abdomen) pain, headache, tiredness (fatigue), upset stomach, dizziness, feeling bloated, belching, gas, stomach flu and heartburn.

Its better to take medication at night.

Do not share your Semaglutide injections with other people, even if the needle has been changed. You may give other people a serious infection, or get a serious infection from them.

Consent to treatment by a physician extender: You may be evaluated and treated by a physician assistant (P.A.) or a nurse practitioner (N.P.) whose recommended care and treatment is subject to supervision and review by a licensed physician.

I HAVE READ AND FULLY UNDERSTAND THIS CONSENT FORM AND I REALIZE I SHOULD NOT SIGN THIS FORM IF ALL ITEMS HAVE NOT BEEN SATISFACTORY EXPLAINED TO ME. WITH MY SIGNATURE I ACKNOWLEDGE THAT MY QUESTIONS HAVE BEEN ANSWERED FULLY, AND THAT I HAVE BEEN REQUESTED TO READ THIS FORM AND HAVE BEEN GIVEN AMPLE TIME TO UNDERSTAND ALL ITS CONTENTS.

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