Semaglutide Consent Form

    Wright Health and Wellness

    Consent for Semaglutide Treatment

    Please read the following information FULLY AND CAREFULLY:

    Every client is an individual, and it is not possible to determine in advance how your system will react to the treatment. It is sometimes necessary to adjust your program as we proceed. It is your responsibility to do your part by following healthy dietary guidelines, exercise your body and make necessary behavioral modifications.

    Semaglutide may cause serious side effects, including:

    Possible thyroid tumors, including cancer. Tell your health care provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. In studies with rodents, Semaglutide and medicines that work like Semaglutide ® caused thyroid tumors, including thyroid cancer. It is not known if Semaglutide will cause thyroid tumors, or a type of thyroid cancer called medullary thyroid carcinoma (MTC) in people.  

    Do not use Semaglutide if you or any of your family have ever had MTC, or if you have an endocrine system condition called Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).

    Do not use Semaglutide if:

    You or any of your family has ever had MTC or if you have MEN 2.

    You are allergic to Semaglutide or any of the ingredients in Semaglutide

    Before using Semaglutide, tell your health care provider if you have any other medical conditions

    Have or have had problems with your pancreas or kidneys. 

    Have a history of diabetic retinopathy.

    Are pregnant or breastfeeding or plan to become pregnant or breastfeed. It is not known if Semaglutide will harm your unborn baby or passes into your breast milk. You should stop using Semaglutide 2 months before you plan to become pregnant.

    Tell your health care provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, herbal supplements, and other medicines to treat diabetes, including insulin or sulfonylureas.

    What are the possible side effects of Semaglutide?

    The most common side effects of Semaglutide may include nausea, vomiting, diarrhea, stomach (abdominal) pain, and constipation.

    Semaglutide may cause serious side effects, including:

    Inflammation of your pancreas (pancreatitis). Stop using Semaglutide and call your health care provider right away if you have severe pain in your stomach area (abdomen) that will not go away, with or without vomiting. You may feel the pain from your abdomen to your back.

    Changes in vision. Tell your health care provider if you have changes in vision during treatment with Semaglutide.

    Low blood sugar (hypoglycemia). Your risk for getting low blood sugar may be higher if you use Semaglutide with another medicine that can cause low blood sugar, such as a sulfonylurea or insulin. Signs and symptoms of low blood sugar may include dizziness or lightheadedness, blurred vision, anxiety, irritability or mood changes, sweating, slurred speech, hunger, confusion or drowsiness, shakiness, weakness, headache, fast heartbeat, and feeling jittery.

    Kidney problems (kidney failure). In people who have kidney problems, diarrhea, nausea, and vomiting may cause a loss of fluids (dehydration), which may cause kidney problems to get worse. It is important for you to drink fluids to help reduce your chance of dehydration.

    Serious allergic reactions. Stop using Semaglutide and get medical help right away if you have any symptoms of a serious allergic reaction, including swelling of your face, lips, tongue, or throat; problems breathing or swallowing; severe rash or itching; fainting or feeling dizzy; or very rapid heartbeat.

    I am aware that other unforeseeable complications could occur. I do not expect the Wright health and Wellness or the providers to anticipate and or explain all risk and possible complications. I rely on them to exercise judgment during the course of treatment. I understand the risks and benefits of the treatment and have had the opportunity to have all of my questions answered.