Consent Form
Weight Management & Prescription Drug Management Consent
This document is intended to serve as a confirmation of informed consent for compounded Semaglutide and Tirzepatide, which are prescription weight management medications.
A. Patient Informed Consent
- I voluntarily request that SlimRX Center (provider) treats my medical condition.
- I have informed my provider of any known allergies, my medical conditions, medications, social/family history.
- I have the right to be informed of any alternative options, side effects, and the risks and benefits.
- I understand the mechanism of action of the medication.
- I understand how it is to be administered.
- I understand the prescription will come from a compounding pharmacy, which is not FDA approved. I have been told that the manufacturing facility itself is FDA monitored along with third party testing on the medication itself.
- Prices may vary and change. My charge will include my time with SlimRX Center (communication via telehealth calls and other forms of interaction), supplies, and medication.
- SlimRX Center may change the pharmacy based on several factors (availability, shipping time, cost). SlimRX Center will tell you as this happens.
- It has been explained to me that this medication could be harmful if taken inappropriately or without advice from the provider.
- I understand this medication may cause adverse side effects (see below). I understand this list is not complete and it describes the most common side effects, and that death is also a possibility of taking this medication. I understand symptoms may be worse after there has been a change in my medication dose or when first starting the medication.
Common side effects include, but are not limited to:
- Gastrointestinal: Nausea/vomiting, abdominal pain, Diarrhea/constipation, dyspepsia, abdominal distension, eructation, flatulence, gastroenteritis, GERD, gastritis, lipase increase, amylase increase
- Neurological: Headache, dizziness
- Cardiac: Heart rate increase, Hypotension
- Endocrine: Fatigue, hypoglycemia (diabetic patients), alopecia
- Ophthalmic: Retinal disorder (diabetic patients)
- Skin: redness or pain at injection site
Serious Reactions include, but are not limited to:
- Thyroid C-cell tumor (animal studies)
- Medullary thyroid cancer
- Hypersensitivity reaction
- Anaphylaxis
- Angioedema
- Acute kidney injury
- Chronic renal failure exacerbation
- Pancreatitis
- Cholelithiasis
- Cholecystitis
- Syncope
B. I understand that I have the following responsibilities:
1. I agree to obtain prescriptions for compounded Semaglutide or tirzepatide only from SlimRX Center.
- If I am looking to transition to a non-compounding pharmacy or seek insurance coverage, I will tell SlimRX Center in advance.
2. Medical history: I will tell SlimRX Center my complete medical history, including allergies, medications, medical/surgical/social/family history.
- Slimrx Center may ask you to review, with your permission, your medical history (medications, recent lab results, pertinent imaging results).
- I understand that if I become pregnant or start trying for pregnancy, I must stop this medication.
- I will be honest to the best of my ability the history she needs to know.
- I will tell my provider any updated health information (medication, allergies, personal medical issues/surgeries/social history, or family history changes).
- My provider can discuss my treatment plan with any co-treating pharmacist and/or healthcare provider.
- I will always tell other providers about all medications I am taking.
- SlimRX Center may ask for me to seek additional labs while on treatment to ensure its safety.
3. Directions for use: I will take my medications only as prescribed according to the directions, led by SlimRX Center.
- If I feel my medications are not effective, or are causing undesirable side effects, I will contact my provider for instructions.
- I will not adjust my medications without prior instruction to do so.
- I understand that the medication must be either kept frozen or refrigerated.
- I understand this medication must be self-injected in the subcutaneous tissue once weekly. I will not inject any less than 7 days unless directed by SlimRX Center (example: travel).
- I will not share needles and dispose of needles safely.
- If I’m having trouble with the administration of the medication, I will seek help from SlimRX Center.
- I will use the medication before and not after the expiration date intended for usage.
4. Refills:
- All refills will require reaching out to SlimRX Center beforehand.
- I understand, I may need to schedule refills ahead of time to avoid delays in refills.
- I will not ask for early refills.
5.Safety:
- I understand it is important to keep my medication away from children (<18 years old)
- I am the only one who will use my medication. I will not give or sell my medication to anyone else.
- If SlimRX Center deems it appropriate to start weaning my medication or transition to maintenance dosing, I will comply.
C. Discontinuation of medication: I understand that SlimRX Center may stop prescribing my medications if:
- I am having unfavorable side effects or it’s not working to treat my medical condition.
- I have been untruthful in my medical or family history.
- I do not follow through with the recommended plan of care set by SlimRX Center.
- I do not follow any parts of “Part B: responsibilities” in this agreement.
I have read this form in its entirety. It has been explained to me. I have had the opportunity to ask questions and have all my questions answered. I fully understand the above information and have no further questions. By signing this form, I voluntarily give my consent for treatment and agree to the risks.