GLP-1/GIP Weiglt Loss Medical Screening

Informed Consent to Participate in Treatment with GLP-1 Agonist

This consent form outlines the agreement between the patient and Hydrations Wellness, it's staff and any affiliates, regarding the use of glucagon-like peptide-1 (GLP-1) receptor agonist medications as part of the patient’s weight management plan. It is crucial for patients to understand the benefits, risks, and responsibilities associated with GLP-1 agonists to ensure safe and effective treatment.

The following information aims to educate the patient on the risks associated with the use of GLP-1 agonists, facilitating understanding and consent to a treatment contract. This consent form is intended to serve as confirmation of informed consent for glucagon-like peptide-1 receptor agonists Injections (Semaglutide or Tirzepatide), which are prescription medications used for weight loss.

About GLP-1 Agonists

GLP-1 (Glucagon-Like Peptide-1) is a hormone produced in the intestines in response to food intake. It plays a crucial role in regulating blood sugar levels by stimulating insulin secretion in a glucose-dependent manner (meaning it only increases insulin release when blood sugar levels are elevated). GLP-1 also suppresses glucagon secretion (a hormone that increases blood sugar levels) and slows down gastric emptying, which helps to control postprandial (after-meal) glucose levels.

Mechanism of Action

GLP-1 receptor agonists bind to and activate GLP-1 receptors on pancreatic beta cells (which produce insulin) and other tissues involved in glucose metabolism. This activation leads to increased insulin secretion in response to meals, reduced glucagon secretion (which decreases glucose production by the liver), and slowed gastric emptying (which helps to prevent rapid rises in blood sugar after eating).

Clinical Use of GLP-1 Agonists

Clinical Use: GLP-1 receptor agonists are typically prescribed along with a reduced-calorie diet and increased physical activity to individuals with type 2 diabetes who have not achieved adequate blood sugar control with other oral medications. GLP-1 agonists, originally developed for the management of type 2 diabetes, have also been approved for weight management due to their beneficial effects on appetite control and metabolism.

Reported Benefits of GLP-1 Agonists

• Effective in promoting weight loss by reducing appetite and increasing feelings of fullness.

• Helps improve blood sugar control by enhancing insulin secretion in response to meals

• Lowers the risk of cardiovascular events, such as heart attack or stroke, in people with type 2 diabetes.

• May improve metabolic health by reducing inflammation and oxidative stress. Typically associated with a lower risk of hypoglycemia compared to other diabetes medications.

Side Effects and Risks of GLP-1 Agonists
Mild side effects may include:

• Nausea: An initial side effect that often improves over time.
• Gastroesophageal Reflux Disease (GERD): Symptoms of acid reflux or heartburn.
• Vomiting: Occasional vomiting, especially early in treatment.
• Diarrhea: Less common but can occur.
• Constipation: Less common but can occur.
• Abdominal Distention: Feeling of bloating or fullness in the abdomen.
• Abdominal Pain: Discomfort or pain in the abdomen.
• Dyspepsia: General discomfort in the upper abdomen.
• Belching: Excessive air or gas in the stomach, leading to burping.
• Flatulence: Increased gas production and passing of gas.
• Headache: Mild to moderate headaches.
• Fatigue: Feelings of tiredness or lack of energy.
• Dizziness: Occasional dizziness or lightheadedness.
• Hypoglycemia: Less common than with other diabetes medications, but can occur, especially when combined with insulin or sulfonylureas.
• Injection Site Reactions: Mild reactions such as redness, bruising, swelling, or itching at the injection site.

In rare cases, serious side effects may include:

• Allergic Reactions: Although rare, allergic reactions including serious hypersensitivity reactions (e.g., anaphylaxis) have been reported with GLP-1 agonists. Patients should seek immediate medical attention if they experience symptoms such as rash, itching, swelling, dizziness, or difficulty breathing.
• Pancreatitis: There is a rare but serious risk of pancreatitis (inflammation of the pancreas) associated with GLP-1 agonists. Symptoms of pancreatitis include severe abdominal pain that may radiate to the back, nausea, and vomiting. Patients should seek immediate medical attention if they experience these symptoms.
• Acute Kidney Injury: In rare cases, GLP-1 agonists have been associated with acute kidney injury. Patients should be monitored for signs of decreased kidney function, such as changes in urine output, swelling in the legs or ankles, and fatigue.
• Thyroid C-Cell Tumors: Studies in rodents have shown an increased risk of thyroid C-cell tumors with some GLP-1 agonists. While this risk has not been definitively established in humans, it is a concern that requires monitoring, particularly in individuals with a personal or family history of medullary thyroid carcinoma (MTC).

Contraindications: Do not take GLP-1 agonist medications if:

• You are allergic to Semaglutide, Tirzepatide, BPC-157, SGLT2 Inhibitors, or any other GLP-1 Agonist.

• You are a Type 1 Diabetic.

• You have a personal or family history of Thyroid C-Cell Tumors, including Medullary Thyroid Carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN-2).

• You have diabetes and are taking other blood sugar-lowering medications without first consulting your PCP or endocrinologist and your Hydrations Wellness clinician.

• You have a history of pancreatitis.

• You have a history of gallbladder disease.

• You have kidney disease or are on dialysis.

• You are pregnant, plan to become pregnant, or are breastfeeding.

• You have other concerning allergies.

• You are taking any other GLP-1 agonist medication.

• You have a history of diabetic retinopathy.

Medical History
Before using this medication, provide your complete medical history and a list of current medications to your Hydrations Wellness clinician. Specifically, inform your clinician about any medications that may lower your blood sugar.

Drug Interactions
GLP-1 medications may delay gastric emptying, affecting the absorption of other oral medications. Monitor and report concerning side effects to your clinician. Please inform your Hydrations Wellness clinician about any medications you are currently taking that may affect blood sugar levels.

Possible drug interactions with GLP-1 agonists include insulin and sulfonylureas due to the increased risk of hypoglycemia (low blood sugar) and corticosteroids due to increased risk of hyperglycemia (high blood sugar) which may necessitate the need for dose adjustment

RELEASE, WAIVER, AND AGREEMENT NOT TO SUE

For purposes of this document (the “Release”), I understand that “Activity” refers to the activity of receiving GLP-1 agonist therapy and everything done in connection with it. I also understand that “Hydrations, LLC” refers to Hydrations LLC, MiDi Holdings LLC; all employees, officers, agents, and contractors.

I understand and appreciate that the Activity involves exposure to potential complications, including ones that I may not know about or anticipate, which may result in property damage, economic loss, bodily or mental injury, or death. I also understand that Hydrations, LLC may not be trained to care for some problems that occur in connection with the Activity.

In consideration of being allowed to participate in the Activity, I agree that:

Hydrations LLC is not responsible for my personal safety or the safety of my property as I participate in the Activity;

My participation in the Activity is entirely voluntary;

My health does not preclude or restrict my participation in the Activity;

I have adequate health and hospitalization insurance and/or accept the financial responsibility for treatment should it become necessary;

Hydrations LLC has permission to authorize emergency medical treatment for me; and

Hydrations LLC has no responsibility for any injury that might occur in connection with that treatment.

Also in consideration of being allowed to participate in the Activity, I agree:

a. To fully assume all the risks and responsibilities of participating in the Activity;

b. To release, waive, and forever discharge any and all claims against Hydrations LLC for any injury to me or damage to m my property resulting from the negligence of Hydrations LLC or anyone else involved with the Activity; and

c. Not to sue Hydrations LLC or to seek any money from it or a judgment against it, for any injury to me or damage to my property resulting from the negligence of Hydrations LLC or anyone else involved with the Activity.

I acknowledge and represent that I have carefully read this Release and understand its contents and that I submit this form as my own free act and deed. I further state that I am at least:

1. Eighteen (18) years of age

2. Fully competent to agree to this Release

3. The consideration for submitting this Release is full and adequate.

4. It is my express intent that, while I am alive, this Release will bind me, my spouse, and the members of my family; and that in the event of my death, this Release will also bind my estate, heirs, administrators, personal representatives, and assigns.

5. I further agree that this Release will be construed under the laws of the State of Illinois, and if any provision of this Release is found to be invalid, the remainder of it will remain valid.

Electronic Signatures

• By providing my electronic signature below, I agree to the terms and conditions outlined in this agreement. I agree to the use of electronic records and signatures. I acknowledge that I have read the related consumer disclosure.

  The parties acknowledge and agree that this agreement form may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. Without limitation, “electronic signature” shall also include faxed versions of an original signature or electronically scanned and transmitted versions (e.g., via PDF) of an original signature.