Terms and Conditions

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

Healthcare Solutions Centers, LLC (HCS) will only be treating you for your weight loss management. HCS will not be treating you for any other medical conditions. If your provider identifies other medical conditions from your labs or assessment you will be asked to see a medical provider not associated with HCS.

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

2. I understand how it is to be administered.

3. I understand the prescription will come from a compounding pharmacy. I have been informed the manufacturing facility is FDA monitored along with third party testing on the medication itself.

4. Prices may vary and change. My program costs include my time with an HCS Provider (in person and via telehealth), supplies, and medication.

5. 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:

• Nausea/vomiting, abdominal pain, Diarrhea/constipation, dyspepsia, abdominal distension, eructation, flatulence, gastroenteritis, GERD, gastritis, lipase increase, amylase increase

• Headache, dizziness

• Heart rate increase, Hypotension

• Fatigue, hypoglycemia (diabetic patients), alopecia

• Retinal disorder (diabetic patients)

• 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

6. I will tell HCS Provider my complete medical history, including: allergies, medications, medical/surgical/social/family history.

a. HCS Provider may ask to review, with your permission, your medical history (medications, recent lab results, pertinent imaging results).

b. I understand that if I become pregnant or start trying for pregnancy, I must stop this medication.

c. I will be honest to the best of my ability the history she needs to know.

d. I will tell my provider any updated health information (medication, allergies, personal medical issues/surgeries/social history, or family history changes).

e. My provider can discuss my treatment plan with any co-treating pharmacist and/or healthcare provider

f. I will always tell other providers about all medications I am taking.

g. HCS Provider may ask for me to seek additional labs while on treatment to ensure its safety.

7. I will take my medications only as prescribed according to the directions from HCS.

a. If I feel my medications are not effective, or are causing undesirable side effects, I will contact my provider for instructions.

b. I will not adjust my medications without prior instruction to do so.

c. I understand that the medication must be 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 HCS Provider.

e. I will not reuse or share needles and dispose of needles safely.

f. If I’m having troubles with the administration of the medication, I will seek help from HCS Provider.

8. Refills:

a. All refills are by appointment only. No one can pick up your medication for you.

9. If HCS Provider deems it appropriate to start weaning my medication or transition to maintenance dosing, I will comply.

10. Discontinuation of medication - I understand that HCS Provider may stop prescribing my medications if:

a. 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

c. I do not follow through with the recommended plan of care set by HCS Provider.

d. I do not follow any (section 6 -10) 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.