By my signature below I do willingly request and consent to Semaglutide or Tirzepatide injections delivered from a compound pharmacy.  I understand that there is no warrant or guarantee of results due largely to off-site administration and patient-controlled application.

1. I understand that as part of this program I will be required to complete a Medical History, listen to an orientation of the program where I will be instructed on how to administer the injections myself, or make arrangements to have someone assist me. I agree to immediately report any problems that might occur to my Primary Care Provider during the treatment program.

2. I understand that there could be risks involved, as there are with all medications. Failure to comply with the dosage recommendation and dietary restrictions could alter the weight loss results.

3. I agree that I am, and will be, under the care of my primary medical provider for all other conditions. I understand that the medical provider who prescribed Semaglutide or Tirzepatide cannot and will not replace my regular Primary Care Physician or General Practitioners or other specialists in Family Medicine or Internal Medicine.

4. I understand that I will only be prescribed Semaglutide or Tirzepatide and will not be prescribed any other type of controlled prescription medications of any kind. We are sometimes asked by patients to provide or renew other medications (such as painkillers or anti-depressants), which were originally ordered by other medical providers. We are not able to comply with such requests.

6. I understand that treatments for weight loss are rarely covered by insurance companies. We do not accept or bill insurance for this program.

7. I understand that results may vary and I understand that any requests for a full or partial refund will NOT be honored. Your prescription is in your individual name and cannot be returned.

8. I have read and understand all of the above statements and conditions and have been informed of potential side effects and risks that may be associated. I fully understand what I am signing and hereby request and consent to using Semaglutide or Tirzepatide. I have disclosed my full medical history and I have been made aware of the benefits, side effects and/or rare possible adverse reactions of various treatments including Semaglutide or Tirzepatide.

9. SEMAGLUTIDE or Tirzepatide CONTRAINDICATIONS! I UNDERSTAND THAT IF I HAVE ANY OF THE FOLLOWING I SHOULD NOT TAKE SEMAGLUTIDE or Tirzepatide  INJECTIONS: Conditions: diabetic retinopathy, a type of damage to the eye from diabetes, low blood sugar, decreased kidney function, pancreatitis, medullary thyroid cancer, multiple endocrine neoplasia type 2, family history of medullary thyroid carcinoma, kidney disease with likely reduction in kidney function.

 

 

10. My electronic signature below I agree to seek immediate medical attention if I exhibit any signs or symptoms of pancreatitis. Signs and symptoms of pancreatitis include upper abdominal pain, abdominal pain that radiates to your back, tenderness when touching the stomach, fever, rapid pulse, nausea, or vomiting.

*You’ll have support from our clinic throughout the term of your program to answer questions about side effects, dosing, and more.

*Syringes and dosing schedule(label from pharmacy) will be included. I also understand that insurance will not cover the program and that the cost is $425-$850

 

12. If you have any questions regarding the side effects or any concerns to contact Health Support Services at (302) 450 4551

I acknowledge that all statements provided on these forms, and the Confidential Health History Forms are true and accurate to the best of my knowledge and that my treatments will be based on the information provided herein and if I willingly withhold information, I accept full liability for any consequence that may arise therefrom.