Semaglutide and other GLP-1 Receptor Agonist medications have been FDA approved (under the trade names “Wegovy”, “Ozempic”, “Mounjaro”) as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of ≥ 30 kg/㎡ (obesity) ≥ 27 kg/㎡ (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, or dyslipidemia)

By checking the Box for this "Weight Loss Patient Consent" form I hereby state that I have read, understood, and agree to the terms of this document, including to the following:

• The medications I am prescribed should not be taken with other medications indicated for diabetes or weight loss without first discussing with your provider.

• The medications prescribed should not be taken if pregnant, breastfeeding, or if you are planning to become pregnant. It should be discontinued at least 2 months prior to pregnancy.

• The most common adverse reactions reported in ≥ 5% of patients treated with GLP-1 receptor agonists are nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dyspepsia, dizziness, abdominal distention, education, hypoglycemia in patients with type 2 diabetes, flatulence, gastroenteritis, and gastroesophageal reflux disease.

• The medications prescribed should not be taken if you have a personal or family history of medullary thyroid cancer (MTC) or Multiple Endocrine Neoplasia (MEN 2). It is unknown if it causes MTC or MEN 2 in humans.

• Rare but serious adverse reactions include the risk for acute pancreatitis, acute gallbladder disease, hypoglycemia, acute kidney injury, hypersensitivity, complications in patients with Type 2 Diabetes, heart rate increase, and suicidal behaviour and ideation.

• I understand any treatments rendered are solely for the purpose of weight control. The diagnosis and treatment of other illnesses and diseases are not the responsibility of this clinic. If I become ill, I will discontinue any diet or medication from this clinic until is determined safe to resume the weight control program

• I will carefully follow the instructions given.

• I will not resell or share the medication with anyone. 

• I will not visit other doctors for the purpose of obtaining additional or duplicate medications of the same type.

• Since most health insurance companies do not provide coverage for the treatment of obesity, we do not take payment from any third-party companies. All services must be paid for at the time of service.

Female Clients: 

• I am not pregnant.

• I will notify the office if I become pregnant.

PROCEDURE AND ALTERNATIVES: I authorize Pondus Medical FL PC., and associates (“Cora Heath Medical”) to assist me in my weight reduction efforts. I understand my treatment may involve, but not be limited to, the use of appetite suppressant for more than 12 weeks and when indicated in higher doses than the dose indicated in the suppressant labelling.

I HAVE READ AND UNDERSTAND MY DOCTOR’S STATEMENT THAT FOLLOW:

“Medications, including appetite suppressants, have labelling working out between the maker of the medication and the Food and Drug Administration. The labeling contains, among other things, suggestions for using the medication. The appetite suppressant labelling suggestions are generally based on shorter-term studies (up to 12 weeks) using the dosages indicated in the labelling. As a physician. I have found the appetite suppressants helpful for periods far in excess of 12 weeks and at times in larger doses than those suggested in the labeling. As a physician, I am not required to use the medication as the labeling suggests but I do use the labeling as a source of information along with my own experience, the experience of my colleagues, recent longer term studies and recommendations of universitybased investigators. Based on these, I have chosen when indicated, to use the appetite suppressants for longer periods of time and at times, in increased doses. Such usage has not been as systematically studied as that suggested in the labeling as it is possible, as with most other medications, that there could be serious side effects as noted below. As a physician, I believe the probability of such side effects is outweighed by the benefit of the appetite suppressant use for longer periods of time and when indicated in increased doses. You must decide if you are willing to accept the risks of the side effects, even if they might be serious, for the possible help of appetite suppressants.”

I understand it is my responsibility to follow the instructions carefully and to report to the doctor treating me for my weight any significant medical problems that I think may be related to my weight control program as soon as reasonably possible. I understand the purpose of this treatment is to assist me in my desire to decrease my body weight and to maintain this weight loss. I understand my continuing to receive the appetite suppressant will be dependent on my progress in weight reduction and weight maintenance. I understand there are other ways and programs that can assist me in my desire to decrease my body weight and to maintain this weight loss.

RISKS OF PROPOSED TREATMENT: I understand this authorization is given with the knowledge that the use of appetite suppressants for more than 12 weeks and in higher doses than the dose indicated in the labeling involves some risks and hazards. The more common include: nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, psychological problems, medication allergies, high blood pressure, rapid heart beat and heart irregularities. these and other risks could, on occasion, be serious or fatal.

RISKS ASSOCIATED WITH BEING OVERWEIGHT OR OBESE: I am aware that there are certain risks associated with remaining overweight or obese. Among them are tendencies to high blood pressure, to diabetes, to heart attack and heart disease, and to arthritis of the joints, hips, knees and feet. I understand these risks may be modest if I am not very much overweight but that these risks can go up significantly with increased obesity.

NO GUARANTEES: I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I also understand that I will have to continue watching my weight all of my life if I am to be successful. I understand that payment in full for all visits and testing is due at the time of my visits, and by submitting to services and testing, I agree to pay for the same in full. Medicare does not, and other medical insurance does not pay for your treatment. I acknowledge and agree to pay all fees as follows. All fees subject to change without notice.

By checking the Box for this "Weight Loss Patient Consent" form I hereby state that I have read, understood, and agree to the terms of this document.