It is important that you are fully aware of the potential risks and side effects of the GLP-1 medication and the weight loss program. Please read the following acknowledgment carefully. By agreeing, you confirm that you have been informed about these risks and that you understand and accept them.

Medication Name: [Tirzepatide (Mounjaro) or relevant GLP-1 medication] – referred to as "the medication."

1. Common Side Effects: I acknowledge that I have been informed of the common side effects associated with the medication. These side effects, as explained by the doctor and literature, may include but are not limited to:

• Gastrointestinal symptoms: nausea, vomiting, diarrhea, constipation, abdominal pain or discomfort, bloating, acid reflux or heartburn. I understand that these are the most frequent side effects, especially when starting the medication or increasing the dose. They are usually mild to moderate and tend to improve as my body adjusts, but in some cases they can be persistent or troublesome.
• Other possible effects: loss of appetite (which is expected as it aids weight loss), changes in taste, headache, fatigue or tiredness, dizziness, or injection site reactions (such as redness, itching, or a small lump where the shot is given). These have been discussed with me. I understand how to manage minor side effects (for example, eating smaller meals to help nausea, staying hydrated, etc.) as per the guidance given.

2. Serious Side Effects and Risks: I acknowledge that I have also been informed of rarer but more serious risks associated with the medication:

• Hypoglycemia (Low Blood Sugar): While I am not diabetic (or if I am, I have told the doctor), GLP-1 medications can lower blood sugar. If I am on any other glucose-lowering medication (like insulin or sulfonylureas), the combination can cause hypoglycemia. The doctor has advised me on signs of low blood sugar (such as sweating, shakiness, confusion) and what to do if it occurs. I will monitor my blood sugar as advised if I'm at risk.
• Pancreatitis: There is a known, though uncommon, risk of pancreatitis (inflammation of the pancreas) with GLP-1 medications. I have been advised of symptoms to watch for, such as severe and persistent abdominal pain that may radiate to the back, nausea/vomiting that doesn't stop, fever, etc. If I experience such symptoms, I will seek immediate medical attention. I understand pancreatitis can be serious and I should discontinue the medication until a doctor evaluates me. I have informed the doctor if I have a history of pancreatitis, gallstones, or very high triglyceride levels, which could predispose me to this risk.
• Gallbladder Disease: Rapid weight loss can increase the risk of gallstones. There have also been some reports of GLP-1 medications being associated with gallbladder issues (e.g., gallbladder inflammation). I will inform the doctor if I develop symptoms like sudden right-sided abdominal pain (especially after fatty meals) or yellowing of eyes/skin (jaundice).
• Thyroid Tumors: In animal studies, this class of medication caused a specific type of thyroid tumor (C-cell tumors). While no such cases have been confirmed in humans at therapeutic doses, out of caution the medication is not recommended for people with a personal or family history of Medullary Thyroid Carcinoma or MEN-2 syndrome. I have informed the doctor of my thyroid history. I understand that I should report any symptoms like a neck mass, difficulty swallowing, or hoarseness. This risk, while theoretical, has been explained and I acknowledge it.
• Allergic Reactions: Serious allergic reactions are rare. However, I know the signs of an allergic reaction: rash or itching that spreads, swelling of the face, lips, tongue or throat, severe dizziness, or trouble breathing. If I experience any of these after taking the medication (especially shortly after an injection), I will treat it as a medical emergency – use appropriate measures if available (like an antihistamine or epinephrine if prescribed) and call emergency services. I have been asked about any known allergies to this class of medication or any component of the drug (like latex in the needle, etc.), and I have disclosed that I have no known allergies to it (or if I have, I would not be on this medication).
• Kidney Issues: I understand that severe vomiting or dehydration from the medication could potentially affect kidney function or even lead to acute kidney injury in vulnerable individuals. I will strive to stay hydrated. If I cannot keep fluids down due to prolonged vomiting, I will contact a doctor.
• Mental Health: I have been told to report any changes in mood, onset of depression, or suicidal thoughts. While not a known common side effect of GLP-1 medications, rapid weight changes or medication effects on the brain could potentially affect mood in some individuals. The program wants to monitor my overall well-being, so I will communicate any mental health concerns.

3. Proper Use and Mitigation: I acknowledge that I have received guidance on how to mitigate some side effects (for example, dietary adjustments to help with nausea, the possibility of dose titration: starting at a lower dose and gradually increasing to mitigate side effects, etc.). I will adhere to those recommendations. I also know that I should not consume excessive alcohol, especially initially, as it could exacerbate certain side effects (like risk of low blood sugar or pancreatitis risk). I will discuss with the doctor before taking any new medications or supplements, as they could interact or add side effect burden.

4. Reporting Side Effects: I agree to promptly report any side effects or unusual symptoms I experience to the program's medical team. This includes both minor side effects that are persistent or bothersome, and any serious symptoms listed above. I understand that the medical team may decide to adjust my dose, temporarily pause the treatment, or discontinue the medication based on my side effect profile for my safety. I will not simply endure severe side effects in silence; I will seek advice, as adjustments can often be made.

5. No Unauthorized Changes: I will not change the medication dose or frequency on my own. I will also not take any other weight loss medications or supplements aimed at weight loss concurrently (outside of what is advised by the program) without medical approval, because doing so could increase risks unpredictably.

6. Acknowledgment of Understanding: I confirm that I have had the opportunity to discuss these potential risks and side effects with the doctor. I have either had a live discussion or have read materials provided (or both) detailing what to expect. My questions have been answered. I fully understand that this treatment has possible side effects, some of which can be serious. Despite this, I voluntarily choose to proceed with the GLP-1 weight loss therapy because I believe the potential benefits to my health and well-being outweigh the risks.

7. Emergency Plan: I have been advised on what to do in case of a severe adverse reaction. Specifically, for any life-threatening reaction (like anaphylaxis) or severe symptoms (like signs of stroke, heart attack, or acute abdomen), I will call emergency medical services immediately. I know that I can also reach out to the program's medical hotline for urgent guidance, but that in true emergencies, immediate local emergency care is paramount.

By agreeing to this Acknowledgment of Risks and Side Effects, I confirm that I understand the above and that I accept the risks. I will engage in the program vigilantly, informed, and in communication with the healthcare team. I understand that this acknowledgment is a key part of informed consent.