Semaglutide Consent

This document is intended to serve as confirmation of informed consent of compounded semaglutide, which is a prescription weight management medication.

A. Patient informed consent

1. I voluntarily request that Bella Skin and Body Treatment Center treat my medication condition. 2. I have informed my provider of any known allergies, my medical condition(s), medications, and social/family history. 3. I have the right to be informed of any alternative options, side effects, and the risks and benefits. . 4. I understand the mechanism of action of the medication. 5. I understand how the medication is to be admin’stered. 6. I understand that the medication will come from a compounding pharmacy, which is not FDA approved. | have been told that the manufacturing facility itself is FDA monitored along with third party testing on the medication itself. 7. Prices may vary and change. My charge will include my time with Bella Skin and Body Treatment Center (in person and via communication outside of the office}, supplies, and medication. also understand that lab fees are an extra cost and agree to be responsible for those fees which will be paid to the lab company directly. 8. Dr2bthin may change the pharmacy based on several factors (availability, shipping, time, cost, etc.). 9. It has been explained to me that this medication could be harmful if taken inappropriately or without advice from the provider. 10. I understand the medication may cause adverse side effects (see below). I understand this list is not complete 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/ccnstipation, dyspepsia, abdominal distention, 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 only from Dr2bthin.
I. If I am looking to transition to a non-compound pharmacy or seek insurance coverage, I will tell Dr2bthin in advance,

2. Medical history: I will tell Dr2bthin my complete medical history, including: Allergies, medications,medical/surgical/social/family history.
II. Dr2bthin may ask to review, with your permission, your medical history (medication, recent lab results,patient imaging results).
III I understand that if I become pregnant or stert trying for pregnancy, I must stop this medication.
IV. I will be honest to the best of my ability the history she needs to know.
V. I will tell my provider any updated health infcrmation (medication,allergies, personal medical issues/surgeries/s2cial history, or family history changes).
VI. My provider can discuss my treatment plan with any co-treating pharmacist and/or healthcare provider.
VII. I will always tell other providers about all medications I am taking.
VIII. Dr2bthin, 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 Dr2bthin.
I. If I feel my medications are not effective, or are causing undesirable side effects, I will contact my provider for instructions.
II. I will not adjust my medications without prior instruction to do so.
III. I understand that the medication must be either kept frozen or refrigerated.
IV. 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 Dr2bthin (Example:travel).
V. I will not share needles and dispose of needles safely.
VI. If I am having troubles with the administration of the medication, I will seek help from Dr2bthin.
VII. The medication expires after 12 weeks. I will refer to the "Beyond Usage Date" (BUD).

4. Refills:
I. All refills will require an appointment.
II. I understand I may need to schedule a recill appointment ahead of time to avoid delays in refills.
III. Refills will get ordered Mondays.
IV. I will not ask for early refills.
V. I understand that I may be asked to bring the medication with me to my appointment to check the quantity left or assess how I am injecting.

5. Safety:
I. I understand it is important to keep my medication away from children (< 18 years old ).
II. I am the only one who will use my medication. I will not give or sell my medication to anyone else.
III. If Dr2bthin deems it appropriate to start weaning my medication or transition to maintenance dosing, I will comply.

C. Discontinuation of medication: I understand that Dr2bthin may stop prescribing my medication if:
  • I am having unfavorable side effects or it is not working to treat my medical condition.
  • I have been untruthful in my medical history.
  • I do not follow through with recommended plan of care set by Dr2bthin.
  • I do not follow any parts of "Part B: responsibilities" in this agreement.
  • I have read this from 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.

Disclaimer:-I have checked with primary care that i can take Semaglutide or Phentermine and i am also aware of the side effects of both these medications and Dr2bthin is not responsible for mu individual side effects.