SLNDR Liability Waver

Weight Management (semaglutide/tirzepatide) Prescription Drug Management Consent This document is intended to serve as a confirmation of informed consent for compounded semaglutide/tirzepatide +/- b12, which is a prescription weight management medication. A. Patient Informed Consent 1. I voluntarily request that Belinda Febles, PA-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 been 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. 7. Prices may vary and change. My charge will include my time with Belinda Febles, PA-C (in person and via communication outside of the office), supplies, and medication. 8. Belinda Febles, PA-C may change the pharmacy based on several factors (availability, shipping time, cost). 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/tirzepatide only from Belinda Febles, PA-C a. If I am looking to transition to a non-compounding pharmacy or seek insurance coverage, I will tell Belinda Febles, PA-C in advance. 2. Medical history: I will tell Belinda Febles, PA-C my complete medical history, including: allergies, medications, medical/surgical/social/family history. a. Belinda Febles, PA-C 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. Belinda Febles, PA-C 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 Belinda Febles, PA-C 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 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. e. I will not share needles and dispose of needles safely. f. If I’m having troubles with the administration of the medication, I will seek help from Belinda Febles, PA-C g. The medication expires after 4 weeks. I will refer to the Beyond Usage Date (BUD). 4. Refills: a. All refills will require an appointment. b. I understand, I may need to schedule refill appointments ahead of time to avoid delays in refills. c. Refills will get pending availability d. I will not ask for early refills. e. 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: a. 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 Belinda Febles, PA-C deems it appropriate to start weaning my medication or transition to maintenance dosing, I will comply. C. Discontinuation of medication: I understand that Belinda Febles, PA-C 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. d. 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. I agree waive all liability rights against Acevedo Medical Care Group, SLNDR HEALTH, LLC, HSR Health, LLC and Belinda Febles, PA-C, Arturo Rojas, PA-C, Jonathan DelValle, PA-C from any complications, infections, death, or any conditions or risks that should arise from todays treatment or any future treatment with compounded semaglutide/tirzepatide +/- vitamin b12 with