Informed Consent GLP-1 for Weight Loss
Glucagon-like peptide-1 (GLP-1) medications are prescribed as one part of a comprehensive lifestyle approach that includes a healthy diet and exercise. GLP-1’s have demonstrated the largest weight loss of any obesity drug to date, semaglutide 15% and tirzepatide 20% of initial weight, accompanied by improvements in cardiovascular risks factors and physical functioning.
I understand Precision Aesthetics is NOT prescribing brand name medications: Ozempic, Wegovy, Moundjaro, Zepbound. We are prescribing a generic medication from a compounding pharmacy in California. Compounded prescription medications, although containing the same ingredient as a branded medication, have not been FDA approved. The manufacturing facility itself is FDA monitored along with third party testing on the medication itself.
I understand this is a completely self-pay treatment program. I understand the cost of the GLP-1 medication may increase based upon pharmacy costs, supply and demand, shipping, availability, etc, which will increase my out of pocket expense.
Any medication needed to treat side effects ie: prescription medication to treat nausea, is not included in the cost of treatment. Your health insurance is likely to cover this cost, but there is no guarantee of coverage. Your health insurance may cover the cost of laboratory testing, but there is no guarantee of coverage.
Before using this medication, you will undergo a complete medical history and physical examination. If laboratory studies have been performed recently, please provide results at Initial Consultation, as you may not need another re-testing. If laboratory studies are needed, I understand I will need to present these results at/before next appointment.
GLP-1 MEDICATIONS ARE FOR
Adults with obesity (BMI ≥30)
Adults who are overweight (BMI ≥27) with-high blood pressure, high cholesterol and/or triglycerides, obstructive sleep apnea or, heart and blood vessel disease.
Adolescents ≥12 years of age with BMI ≥95th percentile standardized for age and sex (usually weight ≥ 130 pounds males, ≥135 pounds females.)
WHO SHOULD NOT TAKE GLP-1
Medullary thyroid cancer (MTC) - Personal or Family History
Multiple Endocrine Neoplasia Type 2 (MEN-2)-Personal or Family History
Pregnancy/Breastfeeding
Already taking: Adlyxin (lixisenatide), Byetta (exenatide), Bydureon (exenatide), Mounjaro (tirzepatide), Ozempic (semaglutide), Rybelsus (semaglutide), Trulicity (dulaglutide), Victoza (liraglutide), Wegovy (semaglutide), or Zepbound (tirzepatide).
GLP-1 medications are given by shallow injection. You may choose your injection site.
GLP-1 Consent-DDD/ 9/13/24-DDD
COMMON SIDE EFFECTS
Digestive: nausea, diarrhea, vomiting, constipation, abdominal pain, headache, dyspepsia, dizziness, abdominal distension, belching, burping, hypoglycemia, flatulence, gastroenteritis, and gastroesophageal reflux disease (GERD).
Other: headache, fatigue, dizziness, runny nose, soreness at Injection site
I understand symptoms may be worse when I first start the medication or increase the dose.
UNCOMMON ADVERSE EVENTS
Anaphylaxis/severe allergy/angioedema - do not take this medication if you have had a serious allergy reaction to it or any of its ingredients.
Pancreatitis - (usually from excessive alcohol use, high triglycerides or genetics).
Symptoms of pancreatitis (inflammation of the pancreas) could include severe upper abdominal pain, sometimes radiating through to the back, and which may or may not be accompanied by persistent or frequent vomiting, dark colored urine, clay-colored stools. Seek immediate emergency medical attention of symptoms are severe or worrisome.
If pain and vomiting are severe and acute pancreatitis is suspected, stop medication and seek urgent medical attention. Laboratory tests will be performed to monitor pancreas function prior to, during treatment, and as needed throughout treatment.
Gallbladder Disease - Occurrence of gallbladder disease was reported in 1.6% of patients. The occurrence of gallstones and gallbladder inflammation was higher in those with severe digestive symptoms. Symptoms of gallbladder disease can include right upper abdominal pain which may feel like its spreading to your right back or shoulder, flatulence, pain after fatty foods, nausea, vomiting, fever, yellowing of the skin or eyes. Seek immediate emergency medical attention of symptoms are severe or worrisome. Laboratory tests will be performed to monitor liver function prior to, during treatment, and as needed throughout treatment.
Kidney Failure - Mainly due to dehydration from severe vomiting, and/or diarrhea. Signs of kidney trouble may include low back or side pain, abdomen pain, difficulty in urination, urine with dark color, odor, decrease in urination frequency and amount. It is very important to stay hydrated, drink at least 32 oz of water per day to avoid constipation and dehydration. Seek immediate emergency medical attention of symptoms are severe or worrisome. Laboratory tests will be performed to monitor kidney function prior to, during treatment, and as needed throughout treatment.
Depression or suicidal thoughts - You should pay attention to any mental changes, especially sudden changes in your mood, behaviors, thoughts, or feelings. If your underlying depression worsens, stop GLP-1 immediately. Seek immediate emergency medical attention of experiencing thoughts or self-harm. Tell your provider right away if you have any mental changes that are new, worse or worrisome.
By signing this form, I voluntarily consent to treatment. I have been fully informed of the potential risks, benefits, and complications. All of my questions/concerns have been addressed to my satisfaction.
I release PRECISION OCCUPATION MEDICAL GROUP/PRECISION AESTHETICS, Donell Deremer PAC, Dr. Ron Goldstein, Dr Shahriar Bamshad, staff members and all agents from any liability or claims arising from the treatment.
