Semaglutide
Consent Form

Please fill out the form prior to your Semaglutide treatment.

Personal Details

First name

Last name

Phone

Date of Birth

Weight Management (semaglutide) Prescription Drug Management Consent

This document is intended to serve as a confirmation of informed consent for compounded semaglutide, which is a prescription weight management medication.

A. Patient Informed Consent

I voluntarily request that Kathleen Sciortino , NP-C (provider) treats my medical condition.
I have informed my provider of any known allergies, my medical conditions, medications, social/family history.
I have the right to be informed of any alternative options, side effects, and the risks and benefits.
I understand the mechanism of action of the medication.
I understand how it is to be administered.
I understand the prescription will come from a compounding pharmacy, which is not FDA approved. I have been told that the manufacturing facility itself is FDA monitored along with third party testing on the medication itself.
Prices may vary and change. My charge will include my time with Kathleen (in person and via communication outside of the office), supplies, and medication.
Kathleen may change the pharmacy based on several factors (availability, shipping time, cost). Kathleen will tell you as this happens.
It has been explained to me that this medication could be harmful if taken inappropriately or without advice from the provider.
I understand this medication may cause adverse side effects (see below). I understand this list is not complete and it describes the most common side effects, and that death is also a possibility of taking this medication. I understand symptoms may be worse after there has been a change in my medication dose or when first starting the medication.

Common side effects include, but are not limited to:

Gastrointestinal: Nausea/vomiting, abdominal pain, Diarrhea/constipation, dyspepsia, abdominal distension, eructation, flatulence, gastroenteritis, GERD, gastritis, lipase increase, amylase increase
Neurological: Headache, dizziness
Cardiac: Heart rate increase, Hypotension
Endocrine: Fatigue, hypoglycemia (diabetic patients), alopecia
Ophthalmic: Retinal disorder (diabetic patients)
Skin: redness or pain at injection site

Serious Reactions include, but are not limited to:

Thyroid C-cell tumor (animal studies)
Medullary thyroid cancer
Hypersensitivity reaction
Anaphylaxis
Angioedema
Acute kidney injury
Chronic renal failure exacerbation
Pancreatitis
Cholelithiasis
Cholecystitis
Syncope

B. I understand that I have the following responsibilities:

I agree to obtain prescriptions for compounded semaglutide only from Kathleen Sciortino, NP-C.
1. If I am looking to transition to a non-compounding pharmacy or seek insurance coverage, I will tell Kathleen in advance.
Medical history: I will tell Kathleen my complete medical history, including: allergies, medications, medical/surgical/social/family history.
1. Kathleen Sciortino, NP-C may ask to review, with your permission, your medical history (medications, recent lab results, pertinent imaging results).
2. I understand that if I become pregnant or start trying for pregnancy, I must stop this medication.
3. I will be honest to the best of my ability the history she needs to know.
4. I will tell my provider any updated health information (medication, allergies, personal medical issues/surgeries/social history, or family history changes).
5. My provider can discuss my treatment plan with any co-treating pharmacist and/or healthcare provider
6. I will always tell other providers about all medications I am taking.
7. Kathleen may ask for me to seek additional labs while on treatment to ensure it’s safety.
Directions for use: I will take my medications only as prescribed according to the directions, led by Kathleen Sciortino, NP-C .
1. If I feel my medications are not effective, or are causing undesirable side effects, I will contact my provider for instructions.
2. I will not adjust my medications without prior instruction to do so.
3. I understand that the medication must be either kept frozen or refrigerated. d. I understand this medication must be self-injected in the subcutaneous tissue once weekly. I will not inject any less than 7 days unless directed by Kathleen (example: travel).
4. I will not share needles and dispose of needles safely.
5. If I’m having troubles with the administration of the medication, I will seek help from Kathleen.
6. The medication expires after 12 weeks. I will refer to the Beyond Usage Date (BUD).
Refills:
1. All refills will require an appointment.
2. I understand, I may need to schedule refill appointments ahead of time to avoid delays in refills.
3. Refills will get ordered Monday.
4. I will not ask for early refills.
5. I understand that I may be asked to bring the medication with me to my appointments to check the quantity left or asses how I am injecting.
Safety:
1. I understand it is important to keep my medication away from children (<18 years old) b. I am the only one who will use my medication. I will not give or sell my medication to anyone else.
If Kathleen deems it appropriate to start weaning my medication or transition to maintenance dosing, I will comply.

C. Discontinuation of medication: I understand that Kathleen may stop prescribing my medications if:

I am having unfavorable side effects or it’s not working to treat my medical condition b. I have been untruthful in my medical or family history
I do not follow through with the recommended plan of care set by Kathleen .
I do not follow any parts of “Part B: responsibilities” in this agreement.

I have read this form in its entirety. It has been explained to me. I have had the opportunity to ask questions and have all my questions answered. I fully understand the above information and have no further questions. By signing this form, I voluntarily give my consent for treatment and agree to the risks.

Your Signature

Date

This form must be signed by the patient or by the legal guardian in the case of a minor or physically/cognitively disabled adult.