INFORMED CONSENT FOR MEDICAL WEIGHT LOSS TREATMENT
BMI & ELIGIBILITY
Weight loss medications are generally prescribed for individuals with obesity or overweight who meet clinical eligibility criteria. In some situations, treatment may be prescribed for off-label use when, in the provider’s professional judgment, the potential benefits outweigh the risks.
Eligibility for treatment is determined solely by the prescribing provider based on the information provided, medical history, current medications, laboratory results (when applicable), and clinical assessment.
Truthfulness of Information
I certify that I am the patient completing this intake and that all information I have provided is true, accurate, and complete to the best of my knowledge.
I understand that my provider will rely on the information I provide when determining whether treatment is safe and appropriate. I understand that failure to disclose medical conditions, medications, allergies, pregnancy status, or other relevant health information may increase my risk of adverse outcomes.
Telehealth Consent
I understand that services provided through Wellness With HLOCare are delivered through telehealth.
I understand that:
- Telehealth has limitations compared to an in-person examination.
- My provider may determine that additional information, laboratory testing, medical records, or an in-person evaluation is required before treatment can be prescribed.
- A prescription is not guaranteed.
- Emergency medical conditions should not be managed through this platform.
If I experience a medical emergency, I will call 911 or seek immediate emergency medical care.
GLP-1 / GIP-GLP-1 Medication Information
I am requesting evaluation for treatment with a GLP-1 receptor agonist or GIP/GLP-1 receptor agonist medication, including but not limited to semaglutide or tirzepatide products.
Potential Benefits
Potential benefits may include:
- Weight loss or weight management
- Reduced appetite
- Improved blood sugar control
- Improved metabolic health
- Reduced cardiovascular risk in certain populations
No specific amount of weight loss or outcome can be guaranteed.
Potential Side Effects
Common side effects may include:
- Nausea
- Vomiting
- Diarrhea
- Constipation
- Abdominal discomfort
- Heartburn or indigestion
- Decreased appetite
- Fatigue
Serious side effects may include:
- Pancreatitis
- Gallbladder disease
- Kidney injury
- Severe dehydration
- Severe allergic reactions
- Gastroparesis or delayed stomach emptying
- Bowel obstruction
- Low blood sugar when combined with certain diabetes medications
- Hospitalization or death in rare circumstances
Risks & Important Considerations
I understand that:
- These medications may not be appropriate for everyone.
- Certain medical conditions may increase my risk of complications.
- Animal studies have shown thyroid tumors with some GLP-1 medications. It is unknown whether these medications cause thyroid cancer in humans.
- I should immediately report severe abdominal pain, persistent vomiting, severe constipation, signs of dehydration, allergic reactions, or any other concerning symptoms.
- Surgery or procedures requiring anesthesia may require temporary discontinuation of GLP-1 medications.
Compounded Medication Disclosure
If prescribed a compounded medication:
- I understand compounded medications are not approved by the U.S. Food and Drug Administration (FDA).
- Compounded medications are not evaluated by the FDA for safety, effectiveness, or quality.
- Compounded medications are prepared by licensed compounding pharmacies for individual patients.
- Alternative FDA-approved medications may be available.
Pregnancy & Reproductive Health
I understand that GLP-1 and GIP/GLP-1 medications should not be used during pregnancy.
I agree to notify Wellness With HLOCare immediately if:
- I become pregnant
- I am planning pregnancy
- I begin breastfeeding
Women using oral contraceptives should discuss contraceptive effectiveness with their provider, as certain medications may affect absorption.
Monitoring & Follow-Up
I understand that ongoing follow-up may be required to:
- Monitor treatment response
- Evaluate side effects
- Review laboratory results
- Determine whether continued treatment is appropriate
I understand that Wellness With HLOCare may request photographs, weight verification, laboratory testing, or additional health information when clinically necessary.
Follow-Up & Refill Requirements
To ensure safe and effective treatment, Wellness With HLOCare requires periodic follow-up assessments. Patients may be required to complete follow-up intake forms, provide updated weight information, submit laboratory results when requested, and report any side effects, medication changes, or changes in their medical history.
Refills, dose adjustments, and continuation of treatment are subject to provider review. Refills may be delayed, modified, or denied if required follow-up forms, laboratory testing, or requested medical information are not completed or provided in a timely manner.
By proceeding with treatment through Wellness With HLOCare, you acknowledge and agree to comply with all required follow-up and monitoring requirements as determined by your provider.
Acknowledgment & Consent
By selecting “I Agree” or clicking “Continue,” I acknowledge that:
- I have read and understand this Informed Consent for Medical Weight Loss Treatment.
- I certify that the information I have provided is true, accurate, and complete to the best of my knowledge.
- I have had the opportunity to review the potential risks, benefits, and alternatives to treatment.
- I understand that no specific results or amount of weight loss can be guaranteed.
- I understand that treatment eligibility and prescription decisions are determined solely by a licensed provider.
- I understand that completing this intake does not guarantee approval or a prescription.
- I consent to telehealth evaluation and treatment through Wellness With HLOCare.
- I voluntarily consent to treatment if deemed appropriate by my provider.
