PATIENT PORTAL

Procedure & Expectations

authorize New Horizon Wellness Clinics to assist me in my weight reduction efforts. I understand my treatment may involve, but is not necessarily limited to, the use of weight management medications being formulated by a compounding pharmacy that meets national standards for safety. I acknowledge that depending on my treatment plan, I might be medicated at doses higher or lower than current dosage indicated in the medication’s labeling. I have read and understand my care team’s statements that follow:

• All prescription medication has labeling determined between its manufacturer and the U.S.Food and Drug Administration. This labeling contains, among other things, suggestions for use. Weight-management medication labeling suggestions are generally based on longer or shorter studies using the dosage indicated on the label.
• As a provider, I am not required to use the medication as the labeling suggests, but I do use the labeling as a source of information along with my own experience, the experience of my colleagues, and recent studies published.
• I consent to having injections of compounded medication is not FDA approved. I realize the pharmacy is an FDA-approved 503-A or 503-B pharmacy.

I understand it is my responsibility to follow the instructions carefully and to report to the provider treating me for my weight any significant medical problems that I think may be related to my weight control program, as soon as reasonably possible. Also, I will notify the provider of all medication I am taking, including anti-depressant medications and herbal supplements. I understand the purpose of this treatment is to assist me in my desire to decrease my body weight and to maintain this weight loss. I understand that my continuing to receive the weight-management medication will be dependent on my progress in weight reduction and adherence to the treatment plan. I understand that any medical treatment may involve risks as well as the proposed benefits. Please see Risk sections below. I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances made to me that the program will be successful. I also understand that obesity may be a chronic, life-long condition that may require drastic changes in eating habits and permanent changes in behavior to be treated successfully. I understand that failing to show up for an appointment I have scheduled, without calling or contacting New Horizon Wellness Clinics 24 hours ahead of time, represents a disruption to operation of the clinic. Failure to show up (“No Show”) for a pre-appointed initial or follow-up visit, or failure to cancel as least one full business day prior to a scheduled visit may result in a fee. Due to the titration regimen of this medication, periods of longer than 2 weeks without taking medication as outlines in treatment plan, will mean that clients will require re-dosing. An additional fee and a new initial intake appointment will need to be made for any clients missing more than 2 consecutive treatment weeks. I have read and fully understand this consent form and “no show” policy. I have had all of my questions answered to my complete satisfaction. I have been given ample time to carefully read and understand this form.

Risks of Proposed Treatment

I understand this authorization is given with the knowledge that the use of the weight-management medication for lower or higher doses than those indicated on the medication label and for individuals that may not meet manufacturer’s criteria involves some risk and hazard. The more common include: nausea, vomiting, skin site reactions, abdominal pain, constipation, diarrhea, fatigue, and headaches. Less common but more serious risks are anaphylaxis reactions to the medication or any of its components, kidney injury, gallbladder diseases, or pancreatitis. These and other possible risks could on occasion be serious or fatal. I understand that any medical treatment may involve risks as well as the proposed benefits. I also understand that there are certain health risks associated with remaining overweight or obese. Risks associated with remaining overweight are tendencies to have high and increasing higher blood pressure, diabetes, heart attack and heart disease, arthritis of the joints including hips, knees, feet and back, sleep apnea, and sudden death. I understand that these risks may be modest if I am not significantly overweight, but will increase with additional weight gain. I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances made to me that the program will be successful. I also understand that obesity may be a chronic, lifelong condition that may require drastic changes in eating habits and permanent changes in behavior to be treated successfully.

***Anecdotally there is reports & patient feedback identifying diminished alcohol tolerance while on semaglutide and tirzepatide. Reports of drastically diminished alcohol tolerance have been shared. Therefore we advise thoughtfully reconsidering driving or operating heavy machinery after any alcohol consumption while on semaglutide and tirzepatide. It can induce nausea and vomiting with alcohol consumption in some individuals***

Semaglutide and Tirzepatide may cause serious side effects, including:

• Inflammation of your pancreas (pancreatitis). Stop using Semaglutide or Tirzepatide and call your healthcare provider right away if you have severe pain in your stomach area (abdomen) that will not go away, with or without vomiting. You may feel the pain from your abdomen to your back. Pancreatitis: Pancreatitis, or an infection in the bile ducts, may be caused by gallstones or the development of sludge or obstruction in the bile ducts. The symptoms of pancreatitis include pain in the left upper abdominal area, nausea, and fever. Pancreatitis may be precipitated by binge-eating or consuming a large meal after a period of dieting. Also associated with pancreatitis is long-term abuse of alcohol and the use of certain medications and increased age. Pancreatitis may require surgery and may be associated with more serious complications and death.


• Gallbladder problems. Semaglutide or Tirzepatide may cause gallbladder problems, including gallstones. Some gallstones may need surgery. Call your healthcare provider if you have symptoms, such as pain in your upper stomach (abdomen), fever, yellowing of the skin or eyes (jaundice), or clay-colored stools. Gall Bladder Disease: Any program resulting in rapid weight loss may precipitate the formation of gallstones, which could lead to cholecystitis (inflammation of your gallbladder), which is a medical urgency or emergency and could require surgery. This is typically because of the rapid weight loss, not the medications you are taking. Symptoms include right upper abdominal pain, abdominal just below your ribs, nausea, and vomiting.


• Increased risk of low blood sugar (hypoglycemia). In patients with type 2 diabetes, especially those who also take medicines for type 2 diabetes such as sulfonylureas or insulin. This can be both a serious and common side effect. Talk to your healthcare provider about how to recognize and treat low blood sugar and check your blood sugar before you start and while you take Semaglutide or Tirzepatide. Signs and symptoms of low blood sugar may include dizziness or light-headedness, blurred vision, anxiety, irritability or mood changes, sweating, slurred speech, hunger, confusion or drowsiness, shakiness, weakness, headache, fast heartbeat, or feeling jittery.


• Kidney problems (kidney failure). In people who have kidney problems, diarrhea, nausea, and vomiting may cause a loss of fluids (dehydration) which may cause kidney problems to get worse. It is important for you to drink fluids to help reduce your chance of dehydration.


• Serious allergic reactions. Stop using Semaglutide or Tirzepatide and get medical help right away if you have any symptoms of a serious allergic reaction, including swelling of your face, lips, tongue, or throat; problems breathing or swallowing; severe rash or itching; fainting or feeling dizzy; or very rapid heartbeat.


• Change in vision in patients with type 2 diabetes. Tell your healthcare provider if you have changes in vision during treatment with Semaglutide or Tirzepatide.


• Increased heart rate. Semaglutide or Tirzepatide can increase your heart rate while you are at rest. Tell your healthcare provider if you feel your heart racing or pounding in your chest and it lasts for several minutes.

BENEFITS

Potential benefits of weight loss, which may include:

• Decreased risk of heart attack.
• Decreased risk of adult onset diabetes mellitus.
• Decreased risk of developing arthritis or musculoskeletal conditions caused by excessive weight.
• Increased emotional and psychological well-being.
• Decreased risk of developing certain types of cancer.

I acknowledge that the medically managed weight loss program recommended to me by New Horizon Wellness Clinics is just one of multiple strategies to reduce weight. Alternative treatment options include:

1. Diet and exercise alone without medications.
2. The use of other kinds of medications to achieve appetite suppression. (Not offered at New Horizon Wellness Clinics).
3. Non-medical weight loss programs (Example: Weight Watchers).

CONTRAINDICATIONS

I understand that I will be determined ineligible to receive compounded Semaglutide or Tirzepatide injections with New Horizon Wellness Clinics if I am less than 18 years old, pregnant, breastfeeding, trying to become pregnant, have Type 1 diabetes, diabetic ketoacidosis, if I have demonstrated an allergy to Semaglutide, Tirzepatide or other GLP-1 RAs in the past, if I have a personal or family history of medullary thyroid carcinoma, a history of multiple endocrine neoplasia syndrome, or a history of pancreatitis. I understand that my medical history will be reviewed and discussed with a provider and I may be determined to be ineligible based on the findings for reasons that are at the discretion of the provider assessment.

IMPORTANT INFORMATION

Before using Semaglutide or Tirzepatide, tell your healthcare provider if you have any other medical conditions, including if you:

• Have or have had depression, suicidal thoughts, or mental health issues.
• Are pregnant or plan to become pregnant. Semaglutide or Tirzepatide may harm your unborn baby. You should stop using Semaglutide or Tirzepatide 2 months before you plan to become pregnant.

REGAINING WEIGHT ACKNOWLEDGEMENT

There is a risk of regaining the weight you have lost. While there are long-term studies identifying the best success with maintaining weight loss on GLP1 medications, obesity is a chronic health condition. As such, the majority of overweight individuals who lose weight have a tendency to regain all or some of it back over time. Factors which favor maintaining weight loss include:

• Exercise.
• Adherence to a calorie intake that is low-calorie, nutritious, and full of lean proteins and vegetables.
• Planning a strategy for coping with weight regain before it occurs.

Successful treatment may take months or even years. Utilizing medications to assist you in your weight loss goals, in addition to diet and exercise, could result in the weight coming back if you do not maintain eating a healthy diet and exercising. Additionally, if you have had fluctuations in your weight in the past, it may be more difficult to maintain the weight you lose.

NO GUARANTEES

I understand that while this program is designed to help with weight reduction, much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful

PHOTOGRAPHS

I consent to have my pictures and/or videos taken and stored in this clinic system. I give permission for photographs to be taken of all sites treated, which will be used to document my medical record. I also give permission for the photographs taken to be used for illustrations of scientific papers or use in educational/training lectures. I understand my name shall not be used in any publication.

COMMUNICATION

I consent to email, text, and phone communications related to post-procedure care and follow-ups.

CONSENT

I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained, or any questions have not been answered to my complete satisfaction. I acknowledge that I have been given time to completely read and understand this form, as well as discuss with my healthcare providers the risks associated with the proposed treatment and other treatments not involving weight-management medications. I do not have any of the contraindications listed above, and I have been forthcoming. Payment is due in full at the time of service and is non-refundable. I understand that this procedure is completely elective and not covered by insurance. Any expenses that may be incurred for the medical care I elect to receive outside of this office for reasons such as, but not limited to, dissatisfaction with my treatment outcome will be my sole financial responsibility. I have received aftercare instructions and agree to follow them, as this will maximize the likelihood of any complications or side effects. I release New Horizon Wellness Clinics and its practitioners of any liability associated with this procedure. I understand that this form of Semaglutide and Tirzepatide is prepared by a nationally reputable compounding pharmacy. No guarantees are made as to the results of this treatment. Multiple treatments may be, and frequently are, necessary to achieve optimal/desired results. My signing of this consent is completely voluntary.