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Tirzepatide Consent Form

    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.

     

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