Tirzepatide Consent Form

    Informed Consent

    Tirzepatide Consent Form


    Wright Health and Wellness

    100 Churchill CT STE 105, Woodstock, GA 30188


    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, 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 or Multiple Endocrine Neoplasia syndrome type 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.

    Important: Do not sign this form unless you have read it carefully and understand the information above.

    Patient Signature


    Please complete the fields below and sign electronically to submit your consent.



    Sign Here

    Sign inside the box below using your mouse or finger.

    If using a mobile device and the signature box does not work, tap “Exit Mobile Version” at the bottom of the screen.


    By submitting this form, I confirm that the information entered is accurate and that I voluntarily consent to treatment.