APT URGENT CARE WEIGHT LOSS SERVICES DISCLOSURE AND CONSENT FORM

Introduction Welcome to APT Urgent Care's Weight Loss Services. We are pleased to offer GLP-1 injection products, such as semaglutide and tirzepatide, as part of our weight loss program. Please read this document carefully. It contains important information about the services we provide, the appropriate use and safety guidelines for GLP-1 products, and details about PHI and HIPAA compliance. Your signature at the end of this document will indicate your understanding and consent to the terms outlined herein.

Service Description Our weight loss program involves the use of GLP-1 (Glucagon-Like Peptide-1) injection products, including semaglutide and tirzepatide, to help manage and reduce weight. These medications are administered via injection and work by mimicking the GLP-1 hormone to increase insulin secretion, suppress appetite, and slow gastric emptying.

Eligibility

• This program is designed for individuals 18 years of age and older.
• Individuals aged 65 and above are recommended to seek advice, management, and treatment from a specialized provider skilled in geriatrics and nutrition before starting this program.
• FDA-Approved Criteria: To be eligible for GLP-1 treatment, patients must meet the following criteria as approved by the FDA:
• Have a body mass index (BMI) of 30 kg/m² or greater (obesity), or
• Have a BMI of 27 kg/m² or greater (overweight) and have at least one weight-related condition such as type 2 diabetes, hypertension, or dyslipidemia.
• Contraindication in Pregnancy: The treatment is contraindicated in pregnancy; therefore, pregnant women are not eligible to receive the treatment.

1. Administration: GLP-1 injections can be administered either by healthcare professionals at APT Urgent Care or by the patient at home. Patients opting for home self-administration will receive detailed instructions and training from our staff.
2. Dosage: Follow the prescribed dosage and administration schedule provided by your healthcare provider. Do not adjust your dose without consulting your healthcare provider.
3. Storage: Store the medication as directed. Typically, GLP-1 products should be kept refrigerated until use.
4. Side Effects: CCommon side effects may include nausea, vomiting, diarrhea, constipation, and abdominal pain. Serious side effects, though rare, may include pancreatitis, thyroid tumors, and kidney problems. Seek medical attention immediately if you experience any severe side effects.
5. Contraindications: Inform your healthcare provider of your complete medical history, especially if you have a history of pancreatitis, thyroid cancer, kidney disease, or gastrointestinal disorders. Pregnant women are not eligible for this treatment.
6. Monitoring: Regular monitoring of your health is necessary while using GLP-1 injections. This may include blood tests and check-ups to assess your response to the treatment.

• Non-Dietician/Nutritionist Role: APT Urgent Care does not claim to practice as dieticians or nutritionists. Our weight loss program is medically supervised, and nutritional guidance will be provided by licensed healthcare professionals.
• Home Self-Administration: Patients choosing home self-administration of GLP-1 injections assume responsibility for following the provided instructions accurately. APT Urgent Care is not liable for any adverse effects resulting from improper self-administration.