INFORMED CONSENT FOR COMPOUNDED GLUCAGON-LIKE PEPTIDE-1 AGONIST (GLP-1) MEDICATIONS | WW USA

INFORMED CONSENT FOR COMPOUNDED GLUCAGON-LIKE PEPTIDE-1 AGONIST (GLP-1) MEDICATIONS

This document is intended to serve as confirmation of informed consent to receive a prescription for a compounded medications, including Glucagon-like Peptide-1 Agonist (GLP-1) Injections (Semaglutide,Tirzepatide or Liraglutide), which are prescription medications used for weight loss.

We are pleased you have chosen one of Weekend Health of Texas, PA, Weekend Health of New Jersey P.C., Weekend Health of Pennsylvania, P.C., Brantley T. Jolly, M.D., Prof. Corp. (collectively, the “WW Clinic Entities” and each a “WW Clinic Entity”) in connection with the services provided through WeightWatchers Clinic for your healthcare needs as they relate to prescriptions for compounded GLP-1 medications. This document is intended to inform you of what you can expect when you decide to take compounded GLP-1 medications, as may be prescribed by your clinician. This Informed Consent for Compounded Medications does not modify or supersede any Terms of Use, Terms of Service, Privacy Policy, Telehealth Informed Consent, or Notice of Privacy Practices of the WW Clinic Entities, rather it supplements these terms and documents.

By checking the box associated with “Compounded GLP-1 Informed Consent”, you acknowledge that you understand and agree with the following:

I do not have any of the following conditions:

A personal or family history of Medullary Thyroid Carcinoma (thyroid cancer)
Multiple Endocrine Neoplasia Syndrome Type 2
A serious allergic reaction to semaglutide or any of the ingredients in Olympia Pharmaceutical compounded semaglutide.
Am pregnant, plan to become pregnant in the next two months, or am breastfeeding
A serious allergic reaction to another GLP-1 medication (a medication similar to what you are being prescribed).

I understand that the following possible side effects may occur. This is not an all-inclusive list. For more information on this medication, you may consult with your prescriber, pharmacist, or other healthcare practitioner,

Most Common Side Effects: Nausea, Vomiting, Diarrhea, Constipation, Abdominal Pain, Headache, Fatigue, Dyspepsia, Dizziness, Abdominal Distention, Belching, Hypoglycemia, Flatulence, Gastroenteritis, Gastroesophageal Reflux Disease, Injection Site Reactions (itching or burning at site of administration with/without thickening of the skin).

Less Common but Serious Side Effects: Pancreatitis (inflammation of the pancreas), hypoglycemia (low blood sugar), acute gallbladder disease including gallstones, acute kidney problems (kidney failure), serious allergic Reactions (including swelling of your face, lips, tongue, or throat, severe rash or itching, very rapid heartbeat, problems breathing or swallowing, or fainting or feeling dizzy), change in vision in people with type 2 diabetes, increase in heart rate (heart racing that lasts for several minutes), depression, or thoughts of suicide.

BLACK BOX WARNING: RISK OF THYROID C-CELL TUMORS

This medication has been found to cause a specific type of thyroid tumor (thyroid C-cell tumors) in rats and mice. It’s not known if this medication can cause similar tumors in humans. Discuss the benefits and risks of this treatment with your clinician. This medication should NOT be used by people with a personal or family history of medullary thyroid carcinoma (MTC) or those with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). While using this medication, contact your clinician immediately if you notice any signs of thyroid tumors, such as an unusual growth or lump in the neck, difficulty swallowing, shortness of breath, or persistent hoarseness.

I understand that certain drug interactions may occur.

I will not use this medication with any other product that contains semaglutide or other medications that are similar to this medication (such as tirzepatide, liraglutide, exenatide, dulaglutide, Wegovy, Ozempic, Rybelsus, Mounjaro, Zepbound, Saxenda, Victoza, or Trulicity).
I understand that when I take compounded semaglutide with other medications by mouth, it might slow down how quickly my stomach empties, which could affect how well my body absorbs other medications. I will update my clinician on a complete list of my medications
The risk of my blood sugar dropping may be higher if I use compounded semaglutide with another medicine that can cause low blood sugar, such as sulfonylureas, insulin, Dipeptidyl peptidase-4 inhibitors (DPP-4s), and meglitinides.
I will keep my health care providers, including my WeightWatchers Clinic clinician, updated on all the medications I am taking, including dietary supplements.

I will follow any directions for use provided to me by my pharmacist or my healthcare provider, including the following:

I understand this medication must be self-injected in the subcutaneous tissues (under the skin) once weekly.
I understand this medication must be kept refrigerated and expires after 28 days of the initial puncture of the medication vial.
I will notify my provider If I experience side effects or if I am having trouble with administration.
I will not share this medication (or needles) with others and agree to dispose of needles and excess medication safely and within 28 days of the initial puncture of medication vial.
I will not adjust any dosage without the express instructions of my Clinician.

I have told my clinician about all of my medical conditions, including:

Any personal or family history of medullary thyroid carcinoma (MTC) or with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
Problems with my pancreas or kidneys
Severe problems with my stomach, including gastroparesis or problems digesting food
Any history of diabetic retinopathy
Am pregnant or plan to become pregnant
Type 1 or type 2 diabetes
History of Pancreatitis
Gallbladder issues
History of Eating Disorders
Depression
Suicidal thoughts or behavior
History of a suicide attempt
All Medications and supplements I am currently taking
Known drug allergies

I give consent for the GLP-1 agonist prescription and the anticipated dosage range. By checking the box next to “Compounded GLP-1 Informed Consent,” i also indicate that I understand the following:

This medication consent is effective immediately. The need for and continued prescriptions for this medication will be reviewed at the clinician’s discretion. I can refuse to give consent or can withdraw my consent at any time with written notification to my assigned clinician. This will not affect my right to change my decision at a later date. If I refuse to give consent or withdraw consent I will not be eligible to receive a prescription for a GLP-1 agonist prescription.

I understand this prescription comes from a compounding pharmacy and is not FDA approved. I understand this medication could be harmful if taken inappropriately and should be used only as prescribed. I acknowledge that no guarantees have been made to me concerning my results. My consent permits the dose to be changed within the anticipated dosage range without signing another consent.

I certify that I have read the contents of this form in its entirety. I have had the opportunity to ask questions and have had my questions answered. I understand the benefits and risks of the medication. I understand that my receipt of this medication is subject to reporting, by my pharmacy, to the prescribing physician, and/or the manufacturer, if required, and I authorize these disclosures. I am 18 years of age or older and authorized to execute this consent form. By signing this form, I voluntarily give my consent for treatment and agree to the risks.