Informed Consent for the Use of Compounded Tirzepatide

(Telehealth or Brick-and-Mortar)

Date: {{current_date}}

Patient Information

• **Patient Name: {{patient_first_name}} {{patient_last_name}} {{patient_first_name}} {{patient_last_name}}** {{patient_input}}
• **Date of Birth: {{patient_birthdate}}** {{patient_input}}

Purpose of This Form

The purpose of this form is to inform you of the potential benefits and risks associated with the use of compounded tirzepatide and to obtain your informed consent to proceed with this treatment.

About Compounded Tirzepatide

This informed consent form is for the use of compounded tirzepatide, a medication that is custom-made for individual patients. Compounded medications are not approved by the U.S. Food and Drug Administration (FDA) and may not have undergone the same level of testing and review as FDA-approved medications.

Tirzepatide is a peptide-based medication that is used to treat obesity and type 2 diabetes. Compounded tirzepatide is a customized form of this medication that is made by a compounding pharmacy to meet the specific needs of an individual patient.

Benefits

The use of compounded tirzepatide may help promote weight loss, improve blood sugar control, and reduce the risk of complications associated with type 2 diabetes.

Risks and Side Effects

Like any medication, compounded tirzepatide may cause side effects, including nausea, vomiting, diarrhea, and headache. In rare cases, more serious side effects such as pancreatitis, gallstones, kidney damage and stomach paralysis may occur.

Important Safety Information

Compounded medications are not approved by the FDA and may not have undergone the same level of testing and review as FDA-approved medications. The safety and efficacy of compounded tirzepatide have not been fully established, and there may be unknown risks associated with its use.

Patient Consent

By signing this form, I acknowledge that I have been fully informed of the potential benefits and risks associated with the use of compounded tirzepatide. I understand that this medication is not FDA-approved and that there may be unknown risks associated with its use. I give my informed consent to proceed with this treatment.

Signatures

Patient Signature: {{patient_input}} Date: {{patient_input}}

Provider Signature: {{patient_input}} Date: {{patient_input}}

Medical Services provided by Primary Medical of KY, P.S.C., Elite Health Services, P.A., CO., Primary Medical of IN, P.C.

Form Complete