Tirzepatide (Mounjaro/Zepbound) Informed Consent

Treatment Overview

Tirzepatide is a dual GIP/GLP-1 receptor agonist used for chronic weight management. Treatment should be combined with diet and exercise. Results vary.

Please Initial Each Statement

• I understand weight loss is not guaranteed.
• I understand common side effects include nausea, vomiting, diarrhea, constipation, decreased appetite and injection-site reactions.
• I understand serious risks include pancreatitis, gallbladder disease, dehydration, kidney injury, allergic reactions and delayed gastric emptying.
• I understand this medication has an FDA boxed warning regarding thyroid C-cell tumors and should not be used with a personal/family history of medullary thyroid carcinoma or MEN2.
• I am not pregnant or breastfeeding and will notify my provider immediately if pregnancy occurs.
• I have disclosed my medical history, medications, allergies and supplements.
• I understand to seek emergency care for severe abdominal pain, persistent vomiting, facial swelling, trouble breathing or vision changes.
• I have had the opportunity to ask questions and consent voluntarily.

Consent

I understand the risks, benefits, alternatives, expected outcomes, and financial responsibility. No guarantees have been made regarding results.