GLP-1 Consent Form

Program Overview

You are being prescribed a GLP-1 receptor agonist medication (such as Semaglutide or Tirzepatide) as part of a medically supervised weight management program.
These medications are designed to help regulate appetite, slow digestion, and improve blood sugar control.

Purpose and Benefits

GLP-1 medications may assist with:

Weight loss and appetite control

Improved blood sugar regulation

Reduced food cravings

Better portion management

Results vary between individuals and depend on lifestyle, nutrition, and adherence to treatment.

Possible Side Effects

Common side effects may include:

Nausea or vomiting

Diarrhea or constipation

Abdominal discomfort or bloating

Fatigue or headache

Less common but serious risks include:

Pancreatitis (inflammation of the pancreas)

Gallbladder issues

Kidney function changes

Allergic reaction or injection site irritation

If you experience severe abdominal pain, vomiting, or persistent nausea, stop the medication immediately and contact your healthcare provider.

Contraindications

You should not take GLP-1 medications if you:

Have a personal or family history of Medullary Thyroid Carcinoma (MTC)

Have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)

Are pregnant, nursing, or planning to become pregnant

Have had severe gastrointestinal disease

Patient Acknowledgment

By ticking the box, you confirm that:

You understand the purpose, benefits, and potential side effects of GLP-1 medications.

You have disclosed all current medications, supplements, and medical history.

You understand this medication is part of a supervised program, and results are not guaranteed.

You agree to follow your provider’s instructions and schedule follow-up appointments as recommended.

You authorize MediDuce Wellness to provide ongoing care, telehealth check-ins, and medication management.

Consent

I have read and fully understand the information above regarding GLP-1 medication treatment.
I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction.
I consent to treatment using GLP-1 medications under the care of MediDuce Wellness.