Treatment With Zepbound (Tirzepatide) – Patient Consent Form NameThis field is for validation purposes and should be left unchanged.Patient's Name(Required)Date of Birth(Required) MM slash DD slash YYYY Purpose of Treatment This disclosure is not meant to alarm you; it is simply an effort to better inform you so that you may give or withhold your consent for this treatment. Zepbound is an FDA-approved medication used to aid in weight management by regulating blood sugar levels and appetite. Potential Benefits and RisksI understand that Zepbound may help:(Required) Support weight loss and appetite control Improve blood sugar regulation (if applicable) Reduce risks associated with obesity and metabolic conditions However, I acknowledge that results vary between individuals, and that weight loss is not guaranteed. I understand that Zepbound like any medication, carries risks, including but not limited to:(Required) Common Side Effects: Nausea, vomiting, diarrhea, constipation, abdominal pain, loss of appetite, and fatigue Serious Risks (though rare): Pancreatitis (severe abdominal pain that may radiate to the back), Gallbladder disease (gallstones, inflammation), Severe allergic reactions (rash, swelling, difficulty breathing), Increased heart rate or palpitations, Thyroid tumors (including medullary thyroid carcinoma) I agree to immediately report any unusual symptoms or side effects to my health care provider.(Required)Patient (or legal guardian) initialContraindications & Precautions I understand that I should not take Zepbound if:(Required) There is a personal or family history of medullary thyroid carcinoma (MTC) or multiple endocrine neoplasia syndrome type 2 (MEN 2). I am pregnant or planning to become pregnant. I have a known allergy to tirzepatide or any ingredients in Zepbound. I will inform my healthcare provider if I have: a history of pancreatitis, severe gastrointestinal disorders (such as gastroparesis), or a history of depression or suicidal thoughts.(Required)Patient (or legal guardian) initialMedication Guidelines & ResponsibilitiesI understand that:(Required) Zepbound is a once-weekly injection and must be used as directed. I should not suddenly stop taking the medication without medical guidance. I should follow a healthy diet and exercise program for the best results. Alcohol consumption may increase the risk of low blood sugar or digestive side effects. I will attend follow-up appointments as recommended to monitor my response to treatment.(Required)Patient (or legal guardian) initialAcknowledgment of Voluntary Participation I have been informed about the potential benefits, risks, and alternative options for weight management. I understand that I have the right to ask questions about this treatment and decline or discontinue treatment at any time. I confirm that I have had a discussion with my healthcare provider regarding Zepbound and that all my questions have been answered to my satisfaction. I acknowledge that I have read and understood the information in this consent form. I voluntarily agree to begin treatment with Zepbound (tirzepatide) and accept the associated risks. This consent is valid unless revoked in writing. Patient (or legal guardian) Print(Required)Patient (or legal guardian) Sign(Required)Date(Required) MM slash DD slash YYYY CAPTCHA Δ