Semaglutide Consent form

Semaglutide Consent form

A human-based glucagon-like peptide-1 receptor agonist like Semaglutide and Tirzepatide are prescribed as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) that is considered outside a healthy range.

While using a GPL-1, it is highly recommended that you:

• Eat a fibrous diet. Focus on fruits and vegetables that are high in fiber. • Eat small high protein meals as digestion is slowed down while on this medication. • Avoid foods high in fat as they take longer to digest. • Limit alcohol intake as this medication can lower blood pressure. • Drink at least 32oz of water a day to avoid constipation.

Do not take this medication if:

• You have a personal or family history of medullary thyroid carcinoma (Thyroid Cancer) • Multiple Endocrine Neoplasia syndrome type 2 • You are pregnant or plan to become pregnant while taking this medicine. • You are diabetic and/or taking any medications related to lowering your blood sugar levels without speaking with your endocrinologist. • Specifically, if you are prescribed Insulin because the combination may increase your risk of hypoglycemia (low blood sugar) and dosage adjustments by your provider may be necessary. • You have a history of Pancreatis. • You are allergic to BPC-157, Semaglutide, Tirzepatide, or any other GLP-1 agonist such as: Adlyxin®, Byeta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy®, Mounjaro; • If you have other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details. Before using this medication, tell your doctor/pharmacist your medical history.

Possible drug interactions:

Anti-diabetic agents, specifically: Insulin and Sulfonylureas (e.g., g lyburide, glipizide, glimepiride, tolbutamide) due to the increased risk of hypoglycemia (low blood sugar). Do not take with other GLP-1 agonist medicines such as: Adlyxin®, Byeta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy®, Mounjaro (THIS IS NOT AN ALL-INCLUSIVE LIST). Other medications used in diabetes, please tell your provider about any medications that may lower your blood sugar.

Possible side effects:

Nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dyspepsia, dizziness, abdominal distension, belching, hypoglycemia, flatulence, gastroenteritis, and gastroesophageal reflux disease. Subcutaneous Injections: common injection site reactions characterized by itching, burning at site of administration with or without thickening of the skin (welting). If you notice other side effects not listed above, contact your doctor or pharmacist. A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing. Report adverse side effects to your doctor or pharmacist. In the event of any emergency, call 911 immediately.

IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THIS TREATMENT, OR ANY QUESTIONS CONCERNING THIS PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK THE STAFF NOW BEFORE SIGNING THIS CONSENT FORM.

By signing, I certify that I have read and understand the contents of this form. I acknowledge that I have a proper laboratory done prior to starting treatment. I am aware of the possible side effects and drug interactions and give my consent for treatment. I have informed the medical staff of any known allergies to drugs or other substances, and any past adverse reactions I’ve experienced. I have informed the medical staff of all medications and supplements I’m currently taking. I understand there are other ways and programs that can assist me in my desire to decrease my body weight and acknowledge that no guarantees have been made to me concerning my results.
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