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Z Med Clinic

Z Medi Clinics and Z Medi Spa

Purpose: I hereby authorize practitioners with this clinic to provide medical care to me, Understanding this, I hereby acknowledge and consent to the following

Qsymia (phentermine and topiramate extended-release) is a combination of a sympathomimetic agent and an anti-seizure medication used to treat individuals who are overweight or obese, in conjunction with diet and exercise, to lose weight and keep the weight off. Phentermine is used by itself to treat obesity.

The exact mechanism by which phentermine works to promote weight loss is not understood, but it is thought to stimulate the release of chemicals from the hypothalamus, the area of the brain known to have a major role in regulating hunger and food intake. The release of these chemicals is thought to reduce appetite and decrease food intake.

Topiramate has been observed to be effective in causing weight loss. The precise mechanism by which topiramate works to stimulate weight loss is not yet understood.

However, similar to the actions of phentermine, topiramate is also thought to suppress appetite and make a person feel full even after eating less food than usual.

Use and distribution of Qsymia is under strict control by the federal government because it contains phentermine, a medicine that has a high potential for abuse and drug dependence. Qsymia is a schedule IV controlled substance.

Common side effects of Qsymia include

Serious side effects of Qsymia include

Drug interactions of Qsymia include monoamine oxidase inhibitor (MAOIs), due to the risk of hypertensive crisis, a condition in which blood pressure becomes dangerously high and can cause organ damage or death.

Qsymia can alter blood concentrations of certain birth control medicines.

Taking Qsymia with alcohol or other CNS depressant drugs (such as barbituratesbenzodiazepines or anti-anxiety agents, and sleep medications) increases the risk of

  • drowsiness,
  • confusion,
  • loss of coordination, and
  • other central nervous system (CNS) depression symptoms.

Taking Qsymia with certain diuretics (water pills) such as hydrochlorothiazide may cause decreased levels of potassium in the blood (hypokalemia).

Qsymia decreases blood levels of carbamazepine and valproic acid.

Administration of topiramate, a component of Qsymia, with carbonic anhydrase inhibitors may increase levels of acid in the blood, which consequently may increase the risk of kidney stone formation.

According to the manufacturer, use of Topirimate, a component of Qsymia, may be associated with birth defects, specifically cleft palate malformation, and should not be used during pregnancy.

Due to the possible risk associated with use of this medication and birth defects, females of reproductive age, who cannot confirm a reliable method of contraception (hysterectomy, tubal ligation, IUD in place) must have a negative pregnancy test performed in the clinic prior to receiving each prescription for Qsymia.

Additionally, females of reproductive age should use effective birth control methods during Qsymia therapy.

Qsymia may be excreted into human milk because topiramate, a component of Qsymia, is known to enter breast milk. Due to the potential risk of causing serious side effects in the nursing infant, a decision should be made to either stop breastfeeding or taking Qsymia

I certify that if any concerns or side effects occur, I will promptly notify Z Med Clinics’ providers. I also understand that Z Med Clinic is not responsible for any manufacturing issues related to these peptides, such as sterility and potency, which are the sole responsibility of the compounding pharmacy preparing them.

I certify that I understand all the above information and that I have no questions about this.

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 SATISFACTORILY 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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