AI WELLNESS CENTER OF EXCELLENCE
WEIGHT LOSS & METABOLIC OPTIMIZATION CONSENT FORM
Semaglutide & Tirzepatide (GLP-1 / GIP Receptor Agonists)
Virtual & In-Person Programs

I authorize the qualified medical providers of AI Wellness Center of Excellence to evaluate me and, if clinically appropriate, prescribe Semaglutide or Tirzepatide, including FDA-approved brand-name products and/or legally compounded formulations, as part of a medical weight loss and metabolic health program.

I understand that these medications are intended for patients with a genuine medical need for weight reduction and metabolic optimization, including overweight or obesity, metabolic dysfunction, insulin resistance or prediabetes, and weight-related health risks.

I understand that these medications are not cosmetic treatments and are not intended for casual or short-term weight loss.

MEDICATION OVERVIEW

I understand that Semaglutide is a GLP-1 receptor agonist and that Tirzepatide is a dual GIP and GLP-1 receptor agonist.

I understand that these medications are administered via subcutaneous injection, typically once weekly.

I understand that these medications work by reducing appetite and cravings, increasing satiety, slowing gastric emptying, and improving insulin sensitivity and glucose regulation.

POTENTIAL BENEFITS

I understand that potential benefits may include reduced appetite and caloric intake, sustainable weight loss when combined with lifestyle changes, improved insulin sensitivity, better blood sugar regulation, and reduction of cardiometabolic risk factors. These benefits are not guaranteed.

I understand that emerging clinical and population-level studies suggest GLP-1–based therapies may reduce systemic inflammation, improve metabolic efficiency, lower cardiovascular risk markers, and potentially support healthier aging when used appropriately.

I acknowledge that longevity and anti-inflammatory benefits are investigational, vary between individuals, and are not guaranteed.

RISKS, SIDE EFFECTS & ADVERSE EVENTS

I understand that common side effects may include nausea, vomiting, diarrhea or constipation, abdominal discomfort or bloating, decreased appetite, fatigue, headache, and gastroesophageal reflux or dyspepsia.

I understand that less common but serious risks may include pancreatitis, gallbladder disease including gallstones, dehydration and electrolyte imbalance, acute kidney injury, delayed gastric emptying or gastroparesis, hypoglycemia (especially when combined with insulin or sulfonylureas), and worsening of diabetic retinopathy in patients with diabetes.

THYROID WARNING

I understand that GLP-1 receptor agonists carry a boxed warning related to medullary thyroid carcinoma and Multiple Endocrine Neoplasia syndrome type 2.

I understand that human risk is not fully established and that use of these medications is contraindicated in patients with these conditions.

CONTRAINDICATIONS

I understand that these medications may not be appropriate for individuals with a personal or family history of medullary thyroid cancer, MEN type 2, type 1 diabetes, diabetic ketoacidosis, pregnancy or breastfeeding, severe gastrointestinal disease such as gastroparesis, or known hypersensitivity to GLP-1 or GIP receptor agonists.

SPECIAL CONSIDERATIONS & PATIENT RESPONSIBILITIES

I understand that women using oral contraceptives should use a non-oral or backup method of contraception for at least four weeks after medication initiation and during dose escalation.

I understand that patients with diabetes must continue care with their primary care provider or endocrinologist and that I must inform all healthcare providers that I am using Semaglutide or Tirzepatide.

I understand that I may not use other GLP-1 medications concurrently unless approved, that medication shortages may occur, and that substitutions may be discussed if necessary.

I understand that lifestyle changes including nutrition, movement, sleep, and stress management are essential for optimal outcomes.

COMPOUNDED MEDICATION DISCLOSURE

I understand that some prescriptions may be filled by licensed compounding pharmacies and that compounded medications are not FDA-approved, but are legally prepared under applicable federal and state pharmacy regulations.

I understand that potency, appearance, and excipients may vary slightly from brand-name products.

TELEHEALTH & VIRTUAL CARE CONSENT

I consent to medical evaluation via telehealth when applicable, electronic communication, electronic prescribing and monitoring, and required periodic virtual check-ins for safety and prescription renewal.

NO GUARANTEE OF RESULTS

I understand that weight loss results are not guaranteed, individual responses vary, medication may be discontinued if risks outweigh benefits, and treatment may be modified or stopped at provider discretion for safety.

VOLUNTARY CONSENT & FINAL ACKNOWLEDGMENT

I certify that I have read and fully understand this consent form, that all questions have been answered to my satisfaction, and that I understand the risks, benefits, alternatives, and limitations.

I freely and voluntarily consent to treatment with Semaglutide and/or Tirzepatide. This document supersedes any prior verbal or written disclosures.