CONSENT FOR SEMAGLITUDE TREATMENT

Semaglutide is a human-based glucagon-like peptide-1 receptor agonist prescribed as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) that is considered outside a healthy range. 

While using Semaglutide it is highly recommended that you: 

• Eat a fibrous diet. Focus on fruits and vegetables that are high in fiber 
• Eat small high protein meals as digestion is slowed down while on this medication 
• Avoid foods high in fat as they take longer to digest 
• Drink at least 32 oz of water a day to avoid constipation 

Do not take this medication if: 

• You have a personal or family history of Thyroid Cancer
• You have a personal history Multiple Endocrine Neoplasia syndrome type 2 (MEN2) 
• You are pregnant or plan to become pregnant
• You are diabetic and/or taking any medications related to lowering your blood sugar levels without speaking with your endocrinologist or primary care provider.
• You are allergic to Semaglutide or any other GLP-1 agonist

Possible drug interactions: 

• Anti-diabetic agents, specifically insulin and sulfonylureas (e.g., glyburide, glipizide, glimepiride, tolbutamide) due to the increased risk of hypoglycemia (low blood sugar). Do not take with other GLP-1 agonist medicines such as: Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy® Maunjaro® (THIS IS NOT AN ALL-INCLUSIVE LIST).
• Blood pressure medications: As weight loss may occur on this medication, it is imperative to monitor your blood pressure at home while on this medication and taking blood pressure medication at the same time. Weight loss may naturally decrease your blood pressure, which may make it necessary to adjust your blood pressure medication dosage. As weight loss occurs, it is recommended to keep a blood pressure diary. 

Possible side effects: 

Nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dizziness, abdominal distension, hypoglycemia, gastroenteritis, and gastroesophageal reflux disease. 

Possible side effects of subcutaneous injections: itching, burning at site of administration with or without thickening of the skin. A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing. 

Semaglutide may cause other serious issues such as 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.

IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THIS TREATMENT, OR ANY QUESTIONS CONCERNING THIS PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK NOW BEFORE SIGNING THIS CONSENT FORM.

By signing, I certify that I have read and understand the contents of this form. I am aware of the possible side effects and drug interactions and give my consent for treatment. I have informed the medical staff of any known allergies to drugs or other substances, and any past adverse reactions I've experienced. I have informed the medical staff of all medications and supplements I'm currently taking. I understand there are other ways and programs that can assist me in my desire to decrease my body weight and acknowledge that no guarantees have been made to me concerning my results. This consent covers the initial and all future prescriptions for this medication. I understand that this is a prescription therapy and is not eligible for a refund or reimbursement.