1661 International Dr, Suite 400, Memphis, TN 38120

800-475-1182

CONSENT TO OZEMPIC, WEGOVY, MOUNJARO
(Semaglutide & Trizeptide Weight Loss Injection)

SEMAGLUTIDE & TIRZEPATIDE

Semaglutide, is sold under the brand names Ozempic as well as Wegovy.

Tirzepatide, is sold under the brand name Mounjaro®.

These are two newest injectable drugs in a group of drugs called GLP-1 receptor agonists (or GLP-1 mimickers). Ozempic was FDA approved for the treatment of type 2 diabetes in December 2017. Wegovy was FDA approved for the treatment of obesity in adults in June 2021. Mounjaro was FDA approved for the treatment of type 2 diabetes in May 2022 and is currently on fast track to be approved for weight loss. In addition to their effects on blood sugar and insulin levels, studies have shown that these medications provided substantial and sustained weight loss.

How does it Work?

Decreases food intake – reduces how much food is eaten
Increases insulin sensitivity – helping the body release insulin when blood sugar is high
Enhances first and second phase insulin secretion – helps the body remove excess sugar from the blood
Slows gastric emptying – slows down how quickly food leaves the stomach (this will lessen over time)
Reduces glucagon levels – stops the liver from making and releasing too much sugar

HOW IS IT ADMINISTERED?

The specific Tirzepatide and Semaglutide dosages and regimen prescribed vary from patient to patient. The injections are prescribed to administered subcutaneously once per week. With a very small needle 31 or 32 gage.

What is the difference between SEMAGLUTIDE & TIRZEPATIDE?

GLP-1 drugs (such as Mounjaro®, Ozempic®, and Wegovy™) are a group of drugs that mimic GLP-1, a hormone the body releases after a meal, signaling you are full and lowering appetite. However, Mounjaro® (Tirzepatide) is unique because it attaches to two different receptors (GLP-1 and GIP), unlike previous GLP-1 analogs, which only attach to one.

How much weight can I expect to lose with SEMAGLUTIDE & TIRAZEPATIDE?

Weight loss results will vary from person to person, but clinical studies have shown that Semaglutide can help to produce significant weight loss in overweight and obese individuals.

In clinical trials for Ozempic, participants lost an average of 13.5 pounds over 26 weeks when used in combination with moderate diet and exercise. In a 68-week study, participants taking Ozempic lost up to 20% of their body weight and those on Wegovy lost an average of 16.0% of their initial body weight, compared to 5.7% for those taking a placebo.

Mounjaro® (Tirzepatide) may result in (may vary depending on individuals & the dosing) better weight loss than Ozempic® and Wegovy (Semaglutides)

WARNINGS

You need to carefully read this consent form along with information on risks and benefits. Although safety is our top priority and we make the best possible effort to make the medication achieve its intended goal with no or minimal side effects, however every patient is unique and if for any reason you experience severe nausea, abdominal discomfort or any allergic reaction, please call us ASAP so we can initiate the appropriate treatment. If symptoms are severe you need to seek emergency help by calling 911.

Although GLP-1 receptor agonists have been prescribed in USA for the last 18 years Exenatide (Byetta), which was approved by the US Food and Drug Administration (FDA) in April 2005 for the treatment of T2DM& carry a stellar safety profile and multiple benefits besides weight loss including cardiovascular benefits, like any pharmaceutical agent, any presently unknown long term post marketing side effects of the medications may surface in course of time. If such happens, Golden weight Loss will not be held liable for the damages.

How Do I Get SEMIGLUTIDE & Tirzepatide?

If you carry a diagnosis of diabetes and would like us to take over your diabetic care, as long as your insurance cover the cost of the medication, our Doctor or Nurse practitioner can try to prescribe you one of the two medications (Ozempic or Mounjaro) as long as you fit the right profile.

If you have a BMI 30 or above, (qualifying for obesity) and you have a commercial insurance that would cover the cost of the medication, we can see you for an office visit and try prescribing you Wegovy as long as you fit the right profile.

If you do not qualify for the above, we can still evaluate you medically and determine if Ozempic, Mounjaro or Wegovy would be a good alternative for your medical needs. This will be regarded as “off label indication”.

The doctor or Nurse Practitioner / Physician Assistant will prescribe you and it will be dispensed to you in our office and we will train you on administering self-injection and storage.

What will it cost me?

Branded medications can be very costly if all is paid out of pocket costing approximately $275 per weekly pen.

If your insurance carrier cover it, it may cost as little as $25/ month to $500 a month when using the discount coupons offered by the Manufactures Novo Nordisk and Eili Lilly. The prescriptions we write or send electronically will need to be redeemed, processed and filled at the pharmacy.

The doses of Wegovy, Ozempic or Mounjaro injections that we offer and dispense at our office range from $50/dose to $175/dose.

This price includes our consultation (visit cost). You need to follow up weekly or once every 4 weeks.

How to take it?

Semiglutide &Tirzepatide are injected under the skin (subcutaneously) of your stomach, thigh, or upper arm. Use these medication shots 1 time each week, at any time of the day. It is not necessary but advisable to (rotate) your injection site with each weekly injection.

PREGNANCY, OTHER ILLNESSES

These medications should not be taken during pregnancy due to higher risk of fetal miscarriages, they are never to be taken if any personal or family history of Medullary Thyroid cancer. We do not prescribe these medications if you have alcoholism or have a history of pancreatitis.

PAYMENT

These medications are generally very safe but your treatment may be off label use if you are not diabetic or have a BMI below 30.If the government insurance plans and commercial plans are not covering the cost of the medications you will be totally responsible for the purchase price. In a very small number of individuals, the injections do not deliver significant results for which no total or partial refunds will be issued.

I hereby voluntarily consent to the above treatment for my medical needs. I have read the above and understand it. My questions have been answered satisfactorily. I accept the benefits, risks and known and unknown complications associated with the medication.

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