1. Introduction
I, the undersigned, consent to participate in the medically supervised weight loss program that may include the use of Tirzepatide, a glucagon-like peptide-1 (GLP-1) receptor agonist, which may aid in appetite control and weight reduction.Tirzepatide is FDA-approved for the treatment of Type 2 diabetes and may be used off-label for weight loss under medical supervision.
2. Purpose of Treatment
The purpose of using Tirzepatide is to assist in weight reduction for patients who are overweight or obese and have not achieved adequate weight loss through diet and exercise alone.
3. Potential Benefits
- Reduced appetite and food intake- Improved blood sugar control- Gradual weight loss- Improved energy and metabolic health
4. Possible Side Effects
I understand that while side effects are usually mild, they can include but are not limited to:- Nausea or vomiting- Constipation or diarrhea- Headache- Dizziness- Fatigue- Injection site reactions- Rare but serious risks include pancreatitis, gallbladder problems, kidney issues, thyroid tumors (including medullary thyroid carcinoma)
5. Contraindications
I affirm that I have disclosed any personal or family history of:- Medullary thyroid carcinoma (MTC)- Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)- Pancreatitis or gallbladder disease- Kidney or liver disease- Pregnancy or breastfeedingI understand that Tirzepatide is not recommended during pregnancy or breastfeeding.
6. Alternative Treatments
I understand that alternative weight loss methods include:- Diet and exercise alone- Prescription medications other than Tirzepatide- Behavioral therapy- Bariatric surgery
7. No Guarantees
I acknowledge that weight loss results vary and cannot be guaranteed. I understand that successful weight loss depends on my adherence to the program, including nutrition, exercise, and follow-up.
8. Acknowledgment and Consent
By signing this form, I certify that:- I have read and understood the information above- I have had the opportunity to ask questions and receive satisfactory answers- I understand the risks and benefits involved- I voluntarily consent to receive Tirzepatide as part of my weight loss treatment
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