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Consent for GLP-1 Assisted Weight-Loss Program and Any Other Offered Weight Loss Program with Medications

 

Warning: Rapid weight loss may cause serious health problems. Rapid weight loss is weight loss of more than 1.5 pounds to 2 pounds per week or weight loss of more than 1 percent of body weight per week after the second week of participation in a weight-loss program.

 

GLP-1 medications has been shown to cause thyroid cancer in some animals. It is not known if I this happens in humans. If thyroid cancer happens, it may be deadly if not found and treated early. Call your doctor right away if you have a neck mass, trouble breathing, trouble swallowing, or have hoarseness that will not go away. Do not use this drug if you have a health problem called Multiple Endocrine Neoplasia syndrome type 2 (MEN 2), or if you or a family member have had thyroid cancer.

 

Tell your provider if:

  • If you are allergic to this drug; any part of this drug; or any other drugs, foods, or substances. Tell your doctor about the allergy and what signs you had.

  • If you have ever had pancreatitis.

  • If you have or have ever had depression or thoughts of suicide.

  • If you are using another drug that has the same drug in it.

  • If you are using another drug like this one. If you are not sure, ask your doctor or pharmacist.

You must inform your primary health care provider or seek immediate medical attention (as indicated) if any of the following occurs:

Allergic Reactions: If you experience a reaction to the injection, you may have sensitivity to GLP-1s. Stop using GLP-1s and seek medical attention immediately.

 

Less serious side effects may occur and include Nausea, Vomiting, Stomach Pain (often during the first 3 - 4 weeks only); Stomach Flu Symptoms (often during the first week only); Upset Stomach, Heartburn, Burping, Gas, Bloating (often during the first week only); Diarrhea, Constipation; In some patients, Headache, Dizziness, Tiredness may occur as a result of rapid weight loss.

 

Other Drugs May Affect GLP-1s

There may be other drugs that can interact with GLP-1s. Tell us about all prescription medication over-the-counter medications, vitamins and any type of supplements you presently use. Do not start taking any new medications or supplements without telling us. The use of steroids or antibiotics while on the program may reduce effectiveness and dramatically slow weight loss.

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FDA understands that sometimes approved products are used to treat conditions that the products were not approved for (i.e., "off-label" uses). The "off-label" use of products usually presents greater uncertainty about both the risks or benefits because less information is available on safety and effectiveness. Unexpected adverse events may occur in this context. ("Off---label" use means the use of FDA approved drugs for purposes other than those for which the FDA has approved them.) "Off---label" prescribing is a legal and common practice in the United States.

 

What are some side effects that I need to call my doctor about right away?

WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect:

  • Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.

  • Signs of kidney problems like unable to pass urine, change in how much urine is passed, blood in the urine, or a big weight gain.

  • Signs of gallbladder problems like pain in the upper right belly area, right shoulder area, or between the shoulder blades; change in stools; dark urine or yellow skin or eyes; or fever with chills.

  • Very bad dizziness or passing out.

  • A fast heartbeat.

  • Change in eyesight.

  • Low blood sugar can happen. The chance may be raised when this drug is used with other drugs for diabetes. Signs may be dizziness, headache, feeling sleepy or weak, shaking, fast heartbeat, confusion, hunger, or sweating. Call your doctor right away if you have any of these signs. Follow what you have been told to do for low blood sugar. This may include taking glucose tablets, liquid glucose, or some fruit juices.

  • Severe and sometimes deadly pancreas problems (pancreatitis) have happened with this drug. Call your doctor right away if you have severe stomach pain, severe back pain, or severe upset stomach or throwing up.

  • New or worse behavior or mood changes like depression or thoughts of suicide.

 

What are some other side effects of this drug?

All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away:

If using for weight loss:

  • Constipation, diarrhea, stomach pain, upset stomach, or throwing up.

  • Headache.

  • Feeling dizzy, tired, or weak.

  • Burping.

  • Gas.

  • These are not all of the side effects that may occur. If you have questions about side effects, call your doctor. Call your doctor for medical advice about side effects.

How is this drug best taken?

 

Use this drug as ordered by your doctor. Read all information given to you. Follow all instructions closely.

Prefilled syringes:

  • It is given as a shot into the fatty part of the skin on the top of the thigh, belly area, or upper arm.

  • If you will be giving yourself the shot, your doctor or nurse will teach you how to give the shot.

  • Take with or without food.

  • Take the same day each week.

  • Move the site where you give the shot with each shot.

  • Do not use if the solution is cloudy, leaking, or has particles.

  • Do not use if solution changes color.

  • Wash your hands before and after use.

  • Keep taking this drug as you have been told by your doctor or other health care provider, even if you feel well.

  • Throw away needles in a needle/sharp disposal box. Do not reuse needles or other items. When the box is full, follow all local rules for getting rid of it. Talk with a doctor or pharmacist if you have any questions.

  • Each container is for one use only. Use right after opening. Throw away any part of the opened container after the dose is given.

 

What do I do if I miss a dose?

  • Take a missed dose as soon as you think about it and go back to your normal time.

  • If it is less than 48 hours until your next dose, skip the missed and go back to your normal time.

  • Do not take 2 doses within 48 hours of each other.

  • If you miss 2 doses, call your doctor.

General drug facts

  • If your symptoms or health problems do not get better or if they become worse, call your doctor.

  • Do not share your drugs with others and do not take anyone else's drugs.

  • Some drugs may have another patient information leaflet. If you have any questions about this drug, please talk with your doctor, nurse, pharmacist, or other health care provider.

  • This drug comes with an extra patient fact sheet called a Medication Guide. Read it with care. Read it again each time this drug is refilled. If you have any questions about this drug, please talk with the doctor, pharmacist, or other health care provider.

  • If you think there has been an overdose, call your poison control center or get medical care right away. Be ready to tell or show what was taken, how much, and when it happened.

 

Based on the above-understanding and my e-signature below, Patient agrees to release Crafted Sustainable Wellness, LLC, its officers, directors, employees, agents and shareholders, and Provider from any and all liability associated with or arising from the Provider's consultation or from the medical, physical, behavioral or other effects of any medication or treatment that may be ordered, prescribed or purchased as a result of the Provider's consultation.

 

This Agreement shall be governed, construed, and enforced in accordance with the laws of the State of Texas, applicable to agreements made and to be made and to be performed entirely within such State, without regard to principles of conflict of laws. Any disputes arising out of, in connection with or with respect to this Agreement, shall be adjudicated in a court of competent jurisdiction sitting in Kendall County, Texas and nowhere else. Patient hereby irrevocably submits to the jurisdiction of such court for the purposes of any suit, civil action or other proceeding arising out of, in connection with or with respect to this Agreement. In the event of any litigation arising out of this Agreement, the prevailing party shall be entitled to recover all expenses and costs incurred, including reasonable attorneys' fees and legal assistants' fees.

 

Patient covenants and agrees to indemnify, defend, protect, and hold harmless, and Provider and their respective officers, directors, employees, stockholders, assigns, successors, and affiliates hereinafter referred to as ("Indemnified Parties") from, against and in respect of all liabilities, losses, claims, damages, punitive damages, causes of action, lawsuits, administrative proceedings, investigation, demands, judgments, settlement payments, deficiencies, penalties, fines, interest and costs and expenses suffered, sustained, incurred or paired by the Indemnified Parties in connection with, resulting from, or arising out of, any acts, directly or indirectly, by Crafted Sustainable Wellness, LLC, their staff and/or Provider's rendering medical care services, advice and/or treatment resulting from Patient's acts or omissions or failure to disclose all relevant information regarding Patient's medical and physical condition. Crafted Sustainable Wellness, LLC and Provider are released from any responsibility to patient that results from acts, omissions or failures of disclosure by patient as mentioned above.

 

Patient is aware of potential side effects associated with the above-described  treatment, accepts all risks involved in taking medication and will not seek damages from the Indemnified Parties of this Agreement.

I the undersigned Patient have read and clearly understand and agree to all the above Terms and Conditions of this Agreementx

from Crafted Sustainable Wellness, LLC.

© 2023 by Crafted Sustainable Wellness

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