Compounded Medication Consent

Last Updated: 01/16/2025

Semaglutide and Tirzepatide Weight Loss Injection Management Consent

This document serves as informed consent for the use of Semaglutide and Tirzepatide weight loss injections for chronic weight management. By signing this form, you acknowledge your understanding of the treatment’s risks, benefits, and alternatives and consent to proceed with this treatment under the care of Nuvo Wellness and Health, LLC.

1. Program Details

Semaglutide and Tirzepatide injections are prescribed as part of a weight management program designed for adults with obesity (BMI >30) or overweight individuals (BMI >27) with at least one weight-related condition such as high blood pressure, Type 2 diabetes, or high cholesterol. These medications are subcutaneous injections that work by mimicking a natural hormone called GLP-1. They help reduce appetite, slow gastric emptying (helping you feel fuller for longer), and increase fat-burning mechanisms. Additional benefits may include: Improved blood sugar control Reduced risk of cardiovascular events related to obesity. A healthy diet and exercise plan are essential for the success of this treatment.

2. Consultation Requirements

You will participate in all required weight loss consultations with a Nuvo Wellness provider. These consultations will assess your medical history, current health status, medications, and weight loss goals. You will receive counseling on nutrition and exercise recommendations to be followed along with your injections. You will be trained on how to perform self-administered subcutaneous injections at home. Your dosage will be tailored to your needs and adjusted as necessary based on your progress and any side effects you experience. Common side effects include nausea, vomiting, diarrhea, abdominal discomfort, constipation, fatigue, and dizziness.

3. Medication Use

Semaglutide and Tirzepatide are prescription medications for weight loss that help reduce appetite and increase satiety. Weight loss is typically 1-2 pounds per week, which is considered healthy. Extreme weight loss is not a desired effect. Weight loss results can vary depending on individual factors such as metabolism, starting weight, and overall health. The initial treatment regimen typically involves weekly injections for 90 days, followed by maintenance doses to sustain weight loss.Results cannot be guaranteed, and Nuvo Wellness and Health, LLC does not offer refunds if desired weight loss is not achieved or side effects occur.

4. Potential Treatment Benefits

Semaglutide and Tirzepatide may provide the following benefits: Weight loss and weight managementImproved blood sugar levels (A1C reduction) Reduced risk of cardiovascular events. However, individual responses to the treatment may vary. Specific benefits cannot be guaranteed.

5. Alternative Treatments

Alternative treatments include: No treatment, Lifestyle modifications (diet, exercise), Other weight management medications, Bariatric surgery (for more severe cases of obesity). Each option has its own set of risks and benefits, which should be discussed with your provider.

6. Potential Risks/Side Effects

Common side effects include: Nausea, vomiting, diarrhea, abdominal pain, constipation. Increased risk of hypoglycemia (low blood sugar) in certain individualsKidney issues, pancreatitis, or retinopathy in some patients Gastroparesis or bowel obstructions in individuals with existing gastrointestinal problems. This list is not exhaustive. Serious side effects are possible, and it is essential to report any unusual symptoms to your provider immediately. For concerns or side effects, please contact Nuvo Wellness and Health, LLC via the Jane portal or by phone (772-210-4649), or seek immediate medical attention if necessary.

7. Contraindications to Treatment

Semaglutide and Tirzepatide are contraindicated for individuals with:

Pregnancy or breastfeeding

Medullary Thyroid Cancer (MTC) or a family history of MTC 

Multiple Endocrine Neoplasia Syndrome type 2 (MEN 2)

Allergic reactions to any of the active ingredients (including Vitamin B12/B6)

Additionally, inform your provider if you have any of the following conditions, as these medications may not be suitable:

Pancreatic or kidney problems

Type 1 or Type 2 diabetes (especially with a history of diabetic retinopathy)

Mental health issues such as depression or suicidal thoughts

Use of insulin or sulfonylureas for diabetesPlease review the FDA warnings for Semaglutide (Wegovy®) and Tirzepatide before starting treatment.

8. Storage, Supply, and Administration

You will be trained on how to administer weekly subcutaneous injections. The injection can be administered in the abdomen, thigh, or upper arm. Medication storage: Keep the medication refrigerated to maintain potency. Adhere to the prescribed schedule and follow-up appointments for best results.

9. Responsibility and Compliance

I am fully responsible for following the prescribed treatment plan, including self-administering injections, attending consultations, following dietary recommendations, and increasing physical activity. Adherence to the program is essential for success.

10. Liability and Acknowledgment

By signing below, I acknowledge:Nuvo Wellness and Health, LLC does not guarantee weight loss results and does not provide refunds for side effects or unmet weight loss goals. No Refund Policy: I understand and agree that Nuvo Wellness and Health, LLC does not offer any refunds for the cost of treatments, medications, or services provided, even if I do not achieve the desired results or experience side effects. I also understand that any payments made are non-refundable. I take full responsibility for my participation and outcomes in this program. I am personally responsible for payment for all services, as most insurance plans do not cover weight loss treatments. If payment is disputed, I agree to cover legal fees and collection costs associated with any non-payment.

11. Indemnification

I agree to defend, indemnify, and hold Nuvo Wellness and Health, LLC harmless from any legal claims or financial responsibility related to my use of this service or prescribed medications.By signing this document, I confirm that I have read, understood, and consent to the terms of treatment outlined above. I acknowledge that I have had the opportunity to ask questions and all concerns have been addressed.