GLP-1 / Medical Weight-Loss Program Consent & Monitoring
Informed consent for GLP-1 receptor agonist therapy (semaglutide, tirzepatide, liraglutide, etc.) in a medical weight-loss program. Covers off-label/compounded drug risks, gastrointestinal side effects, monitoring requirements, contraindications, and program terms.
The GLP-1 / Medical Weight-Loss Program Consent & Monitoring is a ready-to-use healthcare & wellness template you can send for signature in minutes. It is written for 1 signer (patient) and, by default, expires 30 days after it is sent if left unsigned. It covers glp 1, semaglutide, tirzepatide, wegovy, ozempic, mounjaro. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# GLP-1 / Medical Weight-Loss Program Consent & Monitoring **Practice:** ___________ **Prescribing Provider:** ___________, ___________, license number ___________, NPI ___________ **Patient Name:** ___________ **Date of Birth:** ___________ **Date of Consent:** ___________ **Starting Weight:** ___________ **Starting BMI:** ___________ --- ## 1. Description of Treatment You are being enrolled in a medical weight-loss program that includes treatment with a **GLP-1 receptor agonist** and/or **GIP/GLP-1 dual agonist** medication as listed below, along with dietary guidance, activity recommendations, and clinical monitoring. **Medication(s) prescribed:** ___________ *(Examples include: semaglutide [Ozempic®, Wegovy®, Rybelsus®], tirzepatide [Mounjaro®, Zepbound®], liraglutide [Saxenda®, Victoza®], dulaglutide [Trulicity®])* **Route and dosing schedule:** ___________ --- ## 2. FDA-Approved vs. Off-Label vs. Compounded Use The Patient has been informed of the following distinctions: **FDA-approved uses:** - Semaglutide (Wegovy®) and liraglutide (Saxenda®) are FDA-approved for chronic weight management in adults with obesity (BMI ≥ 30) or overweight (BMI ≥ 27) with at least one weight-related condition. - Tirzepatide (Zepbound®) is FDA-approved for chronic weight management. - Semaglutide (Ozempic®, Rybelsus®) and tirzepatide (Mounjaro®) are FDA-approved for type 2 diabetes; use for weight loss in non-diabetic patients is **off-label**.