PATIENT CONSENT FOR WEIGHT LOSS THERAPY AND TREATMENT WITH PEAK MEDICAL WELLNESS.

Payment Terms: Services are to be paid for at the time of service, unless otherwise specified by our staff.

Health Insurance Coverage: Health insurance typically does not cover services provided by Peak Medical Wellness. Should I wish to pursue insurance reimbursement, we would be happy to provide you with itemized invoices for submission to your insurance company. Please note that our services may be tax deductible as a medical expense. It is advised that you speak to a tax professional.

Medication Management: Patients commit to adhering to their prescribed medication regimen, whether it involves controlled substances like Phentermine and Vyvanse or non-controlled substances. Patients affirm that they will not distribute or share my prescriptions with others.

Treatment Purpose and Expectations: Treatments administered at Peak Medical Wellness may not always be deemed medically necessary. They are designed with the goal of enhancing patients overall quality of life. Medications like Semaglutide are intended for use in conjunction with a balanced diet and regular exercise.

Responsibility for Unintended Effects or Illness: Patients agree to promptly seek care from their primary care provider, or in urgent cases, visit an urgent care or emergency department if they experience any unintended side effects or fall ill.

Role of Peak Medical Wellness Providers: Peak Medical Wellness and associated providers do not serve as my primary care providers (PCP). Patients commit to continuing with essential care through my designated PCP and informing them of any treatments prescribed by Peak Medical Wellness. I understand that my PCP’s recommendations may differ, and collaborative decision-making is integral to my health and well-being.

Late or Missed Appointment Policy: In the event of a late arrival or a missed appointment, a fee of $50 may apply. Please note that this policy is subject to change without prior notice.

Payment Terms: Services are to be paid for at the time of service, unless otherwise specified by our staff.

Medication Management: Patient agrees to adhere to my prescribed medication regimen, whether it involves controlled substances like Phentermine and Vyvanse or non-controlled substances. I affirm that I will not distribute or share my prescriptions with others.

Treatment Purpose and Expectations: Treatments administered at Peak Medical Wellness may not always be deemed medically necessary. They are designed with the goal of enhancing my overall quality of life. Medications like Semaglutide are intended for use in conjunction with a balanced diet and regular exercise.

Responsibility for Unintended Effects or Illness: Patient consents to promptly seek care from their primary care provider, or in urgent cases, visit an urgent care or emergency department if they experience any unintended side effects or fall ill.

Role of Peak Medical Wellness Providers: Peak Medical Wellness and associated providers do not serve as my primary care providers (PCP). I commit to continuing with essential care through my designated PCP and informing them of any treatments prescribed by Peak Medical Wellness. I understand that my PCP’s recommendations may differ, and collaborative decision-making is integral to my health and well-being.

Refund and Return Policy: Services and products rendered by Peak Medical Wellness are non-refundable. Additionally, per state regulation, medications cannot be returned once dispensed.

Prescription Issuance Policy: Scheduling an appointment with Peak Medical Wellness does not guarantee the issuance of a prescription, whether for weight loss medication or other medications. Each patient’s case is unique, and the decision to prescribe rests with the medical provider.

Compliance and Follow-Up Appointments: Patients must acknowledge the importance of attending follow-up appointments to maintain continuity of treatment. Providers may determine whether laboratory work is medically necessary for ongoing treatment. The decision to request new lab work or review previously completed results lies with the provider’s discretion.

Informed Consent: Patients affirm that I have received information regarding the potential risks, benefits, complications, and side effects associated with my treatment. Patients fully understand these aspects.

Voluntary Request for Treatment: Patients voluntarily seek treatment from Peak Medical Wellness and associated providers, specifically for weight loss therapy. This decision is based on mutual agreement between the patient and the medical provider. Patients acknowledge that therapy may be recommended not only for weight reduction, but also for weight management and other health-related benefits.

Minors: For all telemedicine visits involving minors, parental consent is mandatory. We ask that parents participate in a portion of the visit to provide their consent for treatment. As a minor, please be aware that there may be certain circumstances in which your parents are legally entitled to receive information about your treatment. We will engage in a conversation with both you and your parents to determine what information is suitable for them to be informed about, and which matters are more appropriately kept confidential.

Termination: I acknowledge that Peak Medical Wellness retains the right to conclude my treatment at any point. This decision is approached with utmost seriousness. Prior to any termination of the medical relationship, we are dedicated to engaging in transparent discussions with you to comprehensively understand the rationale and goals driving such a decision. If, for reasons such as missed follow-up appointments, delayed lab work, or non-compliance with treatment, and unless alternative arrangements have been mutually agreed upon in advance, we may regrettably need to consider the professional relationship as discontinued. This is a necessary step for legal and ethical reasons. In the event that treatment is discontinued, we will provide you with a selection of qualified healthcare provider(s) to ensure the continuity of your care. Alternatively, you have the autonomy to select a provider independently or from another reputable referral source.

Weight Loss Management Prescription Drug (I.e. Semaglutide) Management Agreement

Weight Management (Semaglutide) Prescription Drug Management Agreement

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

Human-based glucagon-like peptide-1 receptor agonists (GLP-1 RA) such as Semaglutude (compounded), Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy® Mounjaro® are prescribed as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) that is considered outside a healthy range.

Weight loss is common with GLP-1 receptor agonist-based therapies. (Source: UpToDate.com)

The subcutaneous preparation of Semaglutide has been shown to reduce major adverse cardiovascular outcomes (driven by a reduction in nonfatal stroke). (Source: UpToDate.com)

While using a GLP-1 RA it is highly recommended that you: Prioritize a fibrous diet with a focus on fruits and vegetables rich in fiber. Opt for small, protein-rich meals to accommodate the slowed digestion associated with this medication. Steer clear of high-fat foods, as they may take longer to digest. Ensure a daily intake of at least 32 ounces of water. Consider limiting or abstaining from alcohol consumption entirely. Alcohol can adversely affect your blood sugar levels, potentially causing them to drop too low when combined with semaglutide. Additionally, alcohol may exacerbate stomach irritation and worsen gastrointestinal side effects when taken in conjunction with this medication.

Do not take this medication if: You have a history of pancreatitis. You have a personal or family history of medullary thyroid carcinoma (Thyroid Cancer). You have a personal history of Multiple Endocrine Neoplasia syndrome type 2 (MEN2). You are pregnant or planning to become pregnant while taking this medicine. It is advised to discontinue these medications for several months before attempting pregnancy. You have type 1 diabetes and/or are taking any medications to lower your blood sugar levels without consulting your primary care provider or endocrinologist. This caution particularly applies if you are prescribed Insulin, as this combination may increase your risk of hypoglycemia (low blood sugar) and necessitate dosage adjustments under the guidance of your provider. You are allergic to Semaglutide or any other GLP-1 agonist, such as Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy® Mounjaro®. (Note: This list is not exhaustive.)

Possible Drug Interactions: Anti-Diabetic Agents: Particularly insulin and sulfonylureas (e.g., glyburide, glipizide, glimepiride, tolbutamide) may pose an increased risk of hypoglycemia (low blood sugar) when taken concurrently. Avoid simultaneous use with other GLP-1 agonist medications like Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy® Maunjaro®. (Note: This list is not exhaustive.)

Blood Pressure Medications: Given that weight loss may accompany this medication, it is crucial to monitor your blood pressure at home while using both this medication and blood pressure medication. Natural weight loss may lead to changes in blood pressure, potentially necessitating adjustments in your blood pressure medication dosage. It is recommended to maintain a log of your blood pressure readings as weight loss progresses.

Possible Side Effects: Nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dyspepsia, dizziness, abdominal distension, belching, hypoglycemia, flatulence, gastroenteritis, and gastroesophageal reflux disease. Note: The side effects associated with GLP-1 receptor agonist-based therapies are primarily gastrointestinal, notably including nausea, vomiting, and diarrhea. These occur consistently in clinical trials, affecting 10 to 50 percent of patients. The risk of hypoglycemia is minimal. However, hypoglycemic events may occur when GLP-1 receptor agonists are combined with diabetes medications known to cause low blood sugar (e.g., insulin, sulfonylureas, glinides).

Possible side effects of subcutaneous injections may include itching, burning at the site of administration, with or without skin thickening.

If you experience any side effects not listed above, please contact your healthcare provider. While severe allergic reactions to this drug are rare, seek immediate medical attention if you observe symptoms such as rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing, sweating, nausea, or vomiting.

GLP-1 RA may lead to other serious issues, including potential thyroid tumors, possibly cancerous. Inform your healthcare provider if you detect any lump or swelling in your neck, experience hoarseness, have difficulty swallowing, or notice shortness of breath. These could be indications of thyroid cancer. Studies with rodents have shown that Semaglutide induced thyroid tumors, including cancer. It remains uncertain if Semaglutide/GLP-1 RA may have similar effects on humans, including a type of thyroid cancer known as medullary thyroid carcinoma (MTC).

Please promptly report any adverse side effects to your clinician. In case of an emergency, dial 911 immediately.

Patient Informed Consent: Patients request Peak Medical Wellness (provider) to provide treatment for their medical condition on a voluntary basis. They have ensured that provider is fully informed of all known allergies, medical history, current medications, and relevant aspects of their social and family history.

Patients acknowledge their entitlement to comprehensive information regarding alternative treatment options, potential side effects, as well as the associated risks and benefits of the proposed course of action.

Patients possess a clear understanding of the mechanism of action of the prescribed medication, along with the proper method of administration.

Patients are aware that the prescription will be sourced from a compounding pharmacy, which may not have FDA approval. I have received assurance that the manufacturing facility undergoes FDA oversight, and the medication itself undergoes third-party testing.

Patients acknowledge that pricing may be subject to variation and change. The charges will encompass the time spent with Peak Medical Wellness (provider), including both in-person consultations and communications conducted outside of the office, as well as the necessary supplies and medication.

Peak Medical Wellness (provider) reserves the right to modify the chosen pharmacy based on considerations such as availability, shipping time, and cost. In the event that pharmacies do not have or stop supplying a particular medication i.e. Semaglutide. An alternative medication may be recommended i.e. Tirzepatide.

It will be clearly communicated to patients that improper or unsupervised use of this medication could lead to harm. I understand the potential for adverse side effects, as outlined below. I recognize that this list is not exhaustive and that mortality is also a possible outcome of taking this medication. I further acknowledge that symptoms may intensify following alterations in my medication dosage or during the initial stages of treatment.

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 (based on animal studies) Medullary thyroid cancer Hypersensitivity reaction Anaphylaxis Angioedema Acute kidney injury Chronic renal failure Pancreatitis Cholelithiasis Cholecystitis Syncope

I understand that I have the following responsibilities: I agree to obtain prescriptions for compounded Semaglutide exclusively from Peak Medical Wellness (provider).

In the event that I intend to shift to a non-compounding pharmacy or explore options for insurance coverage, I will provide advance notice to the clinic.

Patient Medical History Responsibilities: I am committed to providing Peak Medical Wellness with a comprehensive account of my medical history, encompassing allergies, current medications, as well as details regarding medical, surgical, social, and family history.

Peak Medical Wellness (provider) may request, with my consent, to review my medical history, which may include medications, recent lab results, and relevant imaging results.

I am aware that in the event of pregnancy or attempts to conceive, I must discontinue this medication.

I pledge to be forthright to the best of my ability when disclosing my medical history.

I will promptly inform my provider of any updates to my health information, including changes in medication, allergies, personal medical issues/surgeries, social history, or family history.

My provider is authorized to discuss my treatment plan with any co-treating pharmacist and/or healthcare provider, as needed.

I will consistently inform all other healthcare providers about the complete list of medications I am currently taking.

Patient Directions for Medication Use: I will strictly adhere to the prescribed medication regimen as directed by the Peak Medical Wellness provider.

If I experience concerns about the effectiveness of my medications or encounter undesirable side effects, I will promptly contact my provider for further guidance.

I understand that any adjustments to my medications must be made only under prior instruction.

I am aware that the medication must be stored either frozen or refrigerated.

This medication requires self-administration into the subcutaneous tissue once weekly. I commit to not deviating from this schedule, unless directed otherwise by a healthcare professional (e.g., during travel).

I am committed to not sharing needles and will dispose of them safely.

If I encounter difficulties with the administration of the medication, I will seek assistance from a practitioner or other qualified medical professional.

I will make reference to the Beyond Usage Date (BUD) on my prescription(s) as needed.

Safety Measures: If the provider deems it necessary to begin tapering my medication or transition to maintenance dosing, I commit to follow their recommendations.

Possible Discontinuation/Termination of Medication: I understand that the provider may cease prescribing my medications if: a. I experience adverse side effects or if the medication is not effectively addressing my medical condition. b. I provide inaccurate information regarding my medical and/or family history. c. I fail to adhere to the recommended plan of care established by the provider. d. I neglect any aspects outlined within this agreement.

Patients must agree to have read this form in its entirety. They will 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.