TIRZEPATIDE
INFORMED CONSENT FORM

Wright Health and
Wellness

100 Churchill CT STE 105, Woodstock, GA 30188

 

INTRODUCTION

Tirzepatide is a medication used for weight management and
blood sugar control in individuals with Type 2 diabetes. It works by mimicking
the action of natural hormones to regulate insulin secretion and appetite. It
is prescribed off-label for weight loss and metabolic health in
non-diabetic patients.

This form is intended to ensure that you fully understand
the potential benefits, risks, and side effects of Tirzepatide before
starting treatment.

RISKS AND POSSIBLE SIDE EFFECTS

By signing below, you acknowledge that you have been
informed of the potential risks and side effects, including but not limited to:

• Common Side Effects: Nausea, vomiting, diarrhea,
  constipation, decreased appetite, burping, fatigue, or abdominal pain.

• Serious Risks: Pancreatitis, gallbladder disease,
  severe allergic reactions, kidney injury, hypoglycemia (low blood sugar),
  changes in vision, or thyroid tumors.

• Unknown Long-Term Risks: Since Tirzepatide is a
  relatively new medication, long-term risks may not yet be fully known.

• Contraindications: Tirzepatide should not be
  used if you have a personal or family history of medullary thyroid
  carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2
  (MEN 2).

PATIENT RESPONSIBILITIES

I understand and agree that:

1. I must inform Wright Health and Wellness of any medical
   conditions, medications, or allergies before starting Tirzepatide.

2. I am responsible for monitoring and reporting any side
   effects to my provider immediately.

3. I will follow the prescribed dosage and administration
   guidelines as directed.

4. Tirzepatide should be used in conjunction with proper
   diet and exercise for best results.

5. The effectiveness of Tirzepatide may vary, and there
   are no guarantees of weight loss or health improvements.

6. If I experience severe side effects, I will
   discontinue use and seek emergency medical attention.

WAIVER OF LIABILITY

By signing this form, I:

• Acknowledge that Wright Health and Wellness and its
  providers are not responsible for any adverse effects, complications, or
  injuries that may arise from taking Tirzepatide.

• Release Wright Health and Wellness, its providers,
  employees, and affiliates from any legal claims, damages, or liabilities
  related to my use of Tirzepatide.

• Understand that this is an elective treatment, and I am
  choosing to proceed at my own risk.

ALTERNATIVE TREATMENT OPTIONS

I understand that I have other options, including but not
limited to:

• Lifestyle modifications such as diet and exercise

• Other prescription weight-loss or diabetes medications

• No treatment at all

CONSENT AND AGREEMENT

By signing below, I affirm that I:

• Have had an opportunity to discuss this treatment with my
  healthcare provider.

• Have had my questions answered to my satisfaction.

• Understand the risks and benefits of taking Tirzepatide.

• Voluntarily consent to treatment.