top of page

Consent Form

Please fill out the form prior to your Semaglutide treatment.

Personal Details
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 
  1. I voluntarily request that Kathleen Sciortino , NP-C (provider) treats my medical condition.

  2. I have informed my provider of any known allergies, my medical conditions, medications,  social/family history.  

  3. I have the right to be informed of any alternative options, side effects, and the risks and  benefits.  

  4. I understand the mechanism of action of the medication. 

  5. I understand how it is to be administered.  

  6. 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. 

  7. 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. 

  8. Kathleen may change the pharmacy based on several factors (availability, shipping time,  cost). Kathleen will tell you as this happens.  

  9. It has been explained to me that this medication could be harmful if taken inappropriately  or without advice from the provider.  

  10. 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: 
  1. 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. 

  2. 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.  

  3. 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).  

  4. 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.  

  5. 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.  

  6. 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:  
  1. 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 

  2. I do not follow through with the recommended plan of care set by Kathleen .  

  3. I do not follow any parts of “Part B: responsibilities” in this agreement. 

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

Thank you! Please proceed with your booking.

bottom of page