Informed Consent and Medical Intake

Indications and Limitations of Use

Semaglutide/Tirzepatide is an injectable prescription medication for adults with obesity (BMI ≥30) or overweight (excess weight) (BMI ≥27) who also have weight-related medical problems used with a reduced-calorie meal plan and increased physical activity.

Semaglutide/Tirzepatide has not been studied in patients with a history of pancreatitis. Consider other antidiabetic therapies in patients with a history of pancreatitis.

Semaglutide/Tirzepatide is not a substitute for insulin. Semaglutide/Tirzepatide is not indicated for use in patients with type 1 diabetes mellitus or for the treatment of patients with diabetic ketoacidosis.

Contraindications
Semaglutide/Tirzepatide is contraindicated in patients with a personal or family history of Medullary Thyroid Cancer (MTC) or in patients with MEN 2, and in patients with known hypersensitivity to semaglutide or to any of the product components.

Warnings and Precautions
● Risk of Thyroid C-Cell Tumors: Patients should be referred to an endocrinologist for further evaluation if serum calcitonin is measured and found to be elevated or thyroid nodules are noted on physical examination or neck imaging.

● Pancreatitis: Acute and chronic pancreatitis have been reported in clinical studies. Observe patients carefully for signs and symptoms of pancreatitis (persistent severe abdominal pain, sometimes radiating to the back with or without vomiting). If pancreatitis is suspected, discontinue Semaglutide promptly, and if pancreatitis is confirmed, do not restart.

● Diabetic Retinopathy Complications: In a 2-year trial involving patients with type 2 diabetes and high cardiovascular risk, more events of diabetic retinopathy complications occurred in patients treated with Semaglutide (3.0%) compared with placebo (1.8%). The absolute risk increase for diabetic retinopathy complications was larger among patients with a history of diabetic retinopathy at baseline than among patients without a known history of diabetic retinopathy.
Rapid improvement in glucose control has been associated with a temporary worsening of diabetic retinopathy. The effect of long-term glycemic control with semaglutide on diabetic retinopathy complications has not been studied. Patients with a history of diabetic retinopathy should be monitored for progression of diabetic retinopathy.

● Hypoglycemia: The risk of hypoglycemia is increased when Semaglutide/Tirzepatide is used in combination with insulin secretagogues (eg, sulfonylureas) or insulin.

● Acute Kidney Injury: There have been postmarketing reports of acute kidney injury and worsening of chronic renal failure, which may sometimes require hemodialysis, in patients treated with GLP-1 receptor agonists. Some of these events have been reported in patients without known underlying renal disease. A majority of the reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration. Monitor renal function when initiating or escalating doses of Semaglutide in patients reporting severe adverse gastrointestinal reactions.

● Hypersensitivity: Serious hypersensitivity reactions (eg, anaphylaxis, angioedema) have been reported with GLP-1 receptor agonists. If hypersensitivity reactions occur, discontinue use of Semaglutide; treat promptly per standard of care, and monitor until signs and symptoms resolve. Use caution in a patient with a history of angioedema or anaphylaxis with another GLP-1 receptor agonist.

Tell your provider if you have a history of any of those listed.

Adverse Reactions
The most common adverse reactions, reported in ≥5% of patients treated with Semaglutide are nausea, vomiting, diarrhea, abdominal pain, and constipation.

Drug Interactions
The risk of hypoglycemia may be lowered by a reduction in the dose of the secretagogue or insulin. Semaglutide causes a delay of gastric emptying and has the potential to impact the absorption of concomitantly administered oral medications, so caution should be exercised.

Use in Specific Populations
There is limited data with semaglutide use in pregnant women to inform a drug-associated risk for adverse developmental outcomes. Discontinue Semaglutide in women at least 2 months before a planned pregnancy due to the long washout period for semaglutide.
I understand that if I experience any negative side effects that I am to stop the drug immediately and contact my prescriber.

Patient Name*

First NameLast Name

Are you diabetic?*

What have you tried in the past to try to lose weight?

ExerciseFad diets (Paleo, Keto, Atkins, Vegetarian, Mediterranean, Vegan etc)Intermittent FastingGLP 1/Similar injection Medications (Semaglutide, Tirzepatide etc)Bariatric SurgeryOral Medications (Adipex, Phentermine, Saxenda, Contrave etc.)

What did you find to be most effective? If currently taking, what is your current dose?

Are you currently pregnant/breastfeeding or do you plan to become pregnant? *

ANY chance of pregnancy? If no, please explain*

Do you have a personal or family history of Medullary Thyroid Cancer? *

Do you have any history of pancreatitis?*

Do you have any history of acute kidney injury?*

By signing below, you consent to the above discussed risks/benefits of semaglutide and confirm that all health history is accurate to your knowledge. *

Date*

Date of Birth*

Date

Phone Number*

Email*

example@example.com

What is your home address?*

Emergency Contact*

First NameLast Name

Emergency Phone Number*

Gender*

Do you have any Medical concerns?*

YesNo

Height *

Weight*

If "Yes", please elaborate

Do you have any medical conditions? If no, move to next Question. *

Health History

	n/a	No, never	Yes, currently	Not currently, but within the last year	Not currently and longer than 1 year ago
Kidney disease/renal insufficiency
Heart failure
GI bleed
Hormonal
Liver disease
Hypertension
Angina
Ankle swelling
Arrhythmia
Heart attack
Abnormal EKG
Generalized edema
Bleeding disorder
Asthma
Pulmonary edema
Sudden weight loss
Diabetes Type 1
Diabetes Type 2
Diabetic Retinopathy
Anxiety or panic attacks
Are you pregnant?
Are you breastfeeding?
G6PD deficiency
Personal or Family History of Medullary Thyroid Carcinoma
Pancreatitis
Acute Kidney Injury

Please elaborate any other conditions if needed:

**** If you have any of the above medical conditions you may not be medically cleared for Semaglutide use. Please discuss this with your medical team at your initial consultation******

Do you have any allergies?*

YesNo

If any allergies please list them here:*

Are you currently taking any medication? (Including herbal supplements)?*

YesNo

If any medications, please list*

** If a staff member obtains a needle stick injury with potential for blood-to-blood transmission with participant, the participant agrees to obtain formal blood testing to rule out potential of communicable disease transmission via OSHA standards (HIV Hepatitis, etc). Wellness re-InVented, assumes all costs of further necessary testing. Testing shall be performed within 24 hours of needle stick injury at a nearby lab location.

** Wellness re-InVented reserves the right to refuse to initiate or continue treatment at any time based on RN or staff discretion.

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Date Signed

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