By signing below, I hereby acknowledge, agree, and authorize all of the following:

1. Accurate Information. I certify that my information provided here is accurate, complete, and up to date to the best of my knowledge.

2. Consent to Treatment.

a. I voluntarily consent to treatment and accept the known risks and potential side effects that have been explained to me.

b. I acknowledge that the potential benefits, risks, and side effects associated with GLP-1–based medications have been explained to me and that I have had an opportunity to ask questions.

c. I confirm that I will take the medication strictly as directed.

d. I acknowledge that I am responsible for following the treatment plan, medication instructions, laboratory monitoring, follow-up recommendations, and other medical guidance provided to me.

e. I acknowledge that I will provide a copy of my most recent laboratory results within the next six (6) months or before my next prescription is due, whichever comes first.

f. I acknowledge that I have and will continue to visit my primary care physician (PCP) regularly and remain compliant with the care and recommendations provided by my PCP.

g. I confirm that I am not currently pregnant, planning to become pregnant, or breastfeeding. I agree to stop this medication immediately and notify my provider if I become pregnant.

h. I understand that weight-loss results vary depending on diet, exercise, genetics, and individual response to the medication. No specific amount of weight loss has been guaranteed to me.

3. Side Effects.

a. I understand that no medication or treatment is without risk and that no guarantee has been made regarding my individual response or treatment outcome.

b. I understand that the risks and side effects may vary depending on the specific medication prescribed, my medical history, other medications I take, and my individual response to treatment.

c. I agree to promptly notify my healthcare provider of concerning or persistent symptoms and to seek appropriate medical attention when necessary.

d. I understand that possible side effects may include, but are not limited to, nausea, vomiting, diarrhea, constipation, abdominal pain or discomfort, indigestion, decreased appetite, bloating, and other gastrointestinal symptoms.

e. I also understand that more serious complications may occur, including pancreatitis, gallbladder problems, dehydration and kidney problems, severe gastrointestinal reactions, low blood sugar (particularly when used with certain diabetes medications), and serious allergic reactions.

4. Patient Rights and Responsibilities. I understand that the healthcare facility(ies) maintains a Notice of Privacy Practices, which describes how my protected health information may be used and disclosed, and how I may access my health records. I understand that I have the right to review this healthcare facility's Notice of Privacy Practices before signing this form.

5. Release of Medical Information. I authorize the release of my health information to the healthcare facility(ies) in accordance with the healthcare facility's Notice of Privacy Practices. This includes, but is not limited to, releasing medical information to my referring physician, primary care physician, and any physician(s) I may be referred to. The healthcare facility shall ensure all health information remains confidential, as required by HIPAA, and will not release any of my health information without my consent.

6. Consent to Communication. I consent to receiving communications from the healthcare facility(ies) regarding appointment reminders, test results, medication refills, and other necessary healthcare-related information via phone, email, or other channels.