Medical Consent
Tao Cosmetics pllc
DBA (The AdiPosity Clinic)
I, do hereby authorize Dr. Dragotti, DO, The Adiposity Clinic a division of Tao Cosmetics pllc and staff, to assist me with weight reduction using weight loss medications including Glucagon like Peptide (GLP-1) Agonists like Semaglutide or Zepbound (Tirzepatide).
I fully understand that this program shall consist of a weekly subcutaneous self-injection of Zepbound (Tirzepatide) or Semaglutide. Initial dosage of Tirzepatide is (2.5mg/week) , Semaglutide is (0.25mg/week) self-injected weekly.
Increasing weekly dosage is possible as determined by the physician after 4 weeks of treatment at the previous dose. Reduction in caloric intake, regular exercise and behavioral lifestyle changes will enhance weight loss.
I understand that while The Adiposity Clinic currently uses Namebrand Zepbound (Tirzepatide) send directly from Lilly Direct Pharmacy or Semaglutide for their weight loss medications, I am able to go to any pharmacy or lab of my preference for any other non-weight loss medications or lab work needed.
I agree that I am not currently pregnant or breastfeeding, and understand that I cannot become pregnant or breast feed without stopping Tirzepatide/Semaglutide medication first for at least 2 months. The risks of Tirzepatide and other GLP-1 Agonists during pregnancy may cause harm to the fetus and potential risks of birth defects, low birth weight, or miscarriage. The risks of Tirzepatide and other GLP-1 Agonists passing into breast milk are not fully understood and should be avoided. I agree to use other forms of contraception other than oral birth control pills as GLP-1 Agonists may render them ineffective.
I understand that the Initial consultation fee is for evaluation of program suitability by the clinician which is not guaranteed. It does not include medication. A HIPPA safe EMR portal is used for our patient practice and is required to be part of the program and is provided at no additional cost. Medical monitoring for 90 consecutive days is included in initial visit fee of $149 if qualified for medication. A new Physician visit fee of $149 will be charged every 90 days while on the medication. If I am no longer actively participating in The Adiposity Clinic Medical Weight Loss program for a period of 60 days or more, I will be required to pay the initial consultation fee again. Additionally, I will need to submit updated health histories and consent forms and undergo re-evaluation by a clinician.
I understand that I will be self-injecting medication. Different types of instructional material will be sent, and if needed one-on-one Telehealth nurse instruction. Visits with Nurses or Clinicians are typically less than 15 minutes in length. Clinician communication are typically video Telehealth. Nursing communications may be phone, text, email or video Telehealth. Monthly optimized interactions with medical staff, either nurses or clinicians, are scheduled based on the preconfigured patient visit plan. You may not always have the same clinical or nurse for follow ups in order to accommodate your schedule. Number of Clinician visits typically are 4 to 8 per year. For those who require more intensive monitoring than the standard program, additional clinician visits beyond the regular schedule will incur a charge of $100 for up to 15-minute appointments. If multiple additional visits are required, the clinician may determine that this Telehealth program is not a good fit for you and may require in office visits or stop any future continuance with the program or weight loss options they may have.
I further understand that in order to continue to receive Tirzepatide or other weight loss medications from The Adiposity Clinic, I must have regular follow up and show continued weight loss. Regarding the use of appetite suppressants, GLP-1 Agonists in particular, as with any prescription medication, I understand that there are potential risks involved. Side effects may include but not limited to: Nausea, constipation, nervousness, insomnia, headaches, gastroparesis, heart burn, bloating, belching, dry mouth, weakness, fatigue, hypoglycemia, Vomiting, medication allergy, Injection site reactions, Abdominal Pain, Pancreatitis, Gall stone disease, kidney injury, Thyroid Cancer, Eye or kidney damage, acute organ failure, increased or decreased blood pressure, increased or irregular heart rate, Emotional changes or depression, Suicidal thoughts, even risk of death . I understand that these and other risks could be serious or in rare cases life threatening.
I understand that there is no guarantee that this program will work for me and possibly 15% of individuals do not respond fully or at all to GLP-1 medications like Tirzepatide. On the other hand, If weight loss is so great that I am now within or below a normal BMI, The Adiposity Clinic clinician may no longer find me as a suitable candidate for continued medication prescriptions and stop allowing refills.
I understand that if I develop side effects from the medication, I will discontinue taking the medication and notify the The Adiposity Clinic staff immediately and in the event the problem is severe, I will go to the nearest Emergency room for immediate care. I do not have a history of alcohol abuse, drug abuse, schizophrenia, manic-depressive illness, or eating disorder, since these conditions constitute a contraindication to the use of appetite suppressants.
I agree not to take any other weight loss medications, other than those prescribed by The Adiposity Clinic, Dr. Dragotti DO and other Adiposity Clinic practitioners, and other and further agree to inform the staff of ANY changes in my medication or medical history.
I understand that I can be successful without the use of appetite suppressants or injections as long as I am following a reduced calorie nutrition plan and increasing my activity level, however the use of such medications and injections may significantly help with my weight loss progress. I understand the risks associated with being overweight or obese include the possibility of high blood pressure, diabetes, heart disease, stroke, cancer, arthritis and pain of the joints, gallbladder disease and even sudden death.
I understand that Bariatric Physicians have found appetite suppressants & weight loss medications helpful for periods longer than those suggested in the medication labeling and at times in larger doses. The Adiposity Clinic Dr. Dragotti and other clinic practitioners are not required to use the medications as the labeling suggests but does use it as a source of information along with their own experience, the experiences of their colleagues, as well as recent studies and recommendations of investigators and professional societies.
I also understand that refunds are not provided for: 1. Initial visit if not cancelled or rescheduled prior to 48 hours of appointment. 2. Medication that has been sent to your pharmacy and not received or unavailable, spilled or wasted medication, medication not kept refrigerated, or for any unused portions of medication or monitoring.
I understand that The Adiposity Clinic, Dr. Dragotti DO and clinic practitioners and medical personnel are not replacing your need for a Primary Medical Physician ( PCP) and are solely managing weight loss medication they prescribe. Lab abnormalities will still need to be reviewed by your PCP for possible further management.
By signing below I certify that I have read and fully understand this consent form and understand the risks and benefits associated with my treatment for weight loss.
I HAVE READ AND FULLY UNDERSTAND THIS CONSENT FORM AND I REALIZE I SHOULD NOT SIGN THIS FORM IF I HAVE QUESTIONS REGARDING THIS CONSENT