FOYZ01 Weight Loss Medication Consent Form

I, the above named patient, authorize Ashley Caldwell (nurse practitioner) and staff at 4You LLC to assist me at the weight loss. I understand that the program may consist of caloric deficit, exercise, behavior modification, and may involve the use of weight loss medications. I further understand that if medications are used, they may be used for specific durations of time that may exceed the medication package insert. I understand it is my responsibility to read the medication consent forms below and can also do further research on any medication before commencing treatment.

I understand that any medical treatment may involve risks ass well as the proposed benefits. I also understand there are certain health risks associated with remaining overweight or obese. Risks of this program may include, but are not limited to nervousness, sleeplessness, headaches, dry mouth , gastrointestinal disturbances, weakness, fatigue, physiological problems, high blood pressure, rapid heart beat, heart irregularities. These and other possible risks could, on occasion but serious or even fatal. Risks associated with remaining overweight are tendencies to high blood pressure, diabetes, heart attack, heart disease, arthritis, sleep apnea, or even sudden death. I understand these risks may be modest if I am not significantly overweight, but will increase with additional weight gain.

I understand that much of the success of the program will depend on my efforts, and that there are no guarantees or assurances that this program will be successful. I understand that obesity may be a chronic, lifelong condition that may require changes and eating habits and permanent changes in behavior to be treated successfully.

I have read and fully understand this consent form, and I realize I should not sign this form if I do not wish to proceed with this program. I have been urged and have been given all the time I need to read and understand this form.

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I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

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Date

PLEASE READ ABOUT ALL MEDICATIONS BELOW:

Links for each medication has also been provided for more in-depth information regarding each medication. We request that you read and sign consents for all medications that way if medications are changed throughout your course of treatment, you have already completed the consent. We will always discuss each medication with patients prior to prescribing; however this is the opportunity for you to read in more detail. We have highlighted the most common interactions and side effects related to each medication we commonly prescribe below. Please do not hesitate to ask questions. Please note, patients CANNOT be pregnant or breast feeding on ANY of the medications prescribed.

Common Medications Prescribed for Weight Loss:

Semaglutide (Ozempic, Wegovy, or compounded semaglutide/cyanocobalamin:

Full medication information can be found at the following links:
Ozempic: https://www.ozempic.com
Wegovy:
https://www.wegovy.com/?showisi=true&&utm_source=google&utm_medium=cpc&utm_t
erm=wegovy&utm_campaign=1_All_Shared_BR_Wegovy_Core&mkwid=s-dc_pcrid_6452
89260650_pkw_wegovy_pmt_e_slid__product_&pgrid=146393443618&ptaid=kwd-129642
6946962&gad_source=1&gclid=CjwKCAjwhIS0BhBqEiwADAUhc6PlqN4amJe62hPb477v9
qcYpSif91-4Q2jrxx6Ozy1kmZk5o_1fGhoCMdkQAvD_BwE&gclsrc=aw.ds

Compounded semaglutide/cyanocobalamin:
https://www.empowerpharmacy.com/compounding-pharmacy/semaglutide-cyanocobala
min-injection/

Semaglutide (Ozempic, Wegovy, or compounded semaglutide/cyanocobalamin):
This is an injectable prescription medicine used with a reduced calorie diet and
increased physical activity:

to reduce the risk of major cardiovascular events such as death, heart attack,
or stroke in adults with known heart disease and with either obesity or
overweight.
that may help adults and children aged 12 years and older with obesity, or
some adults with overweight who also have weight-related medical problems,
to help them lose excess body weight and keep the weight off.

Semaglutide (Ozempic, Wegovy, or compounded semaglutide/cyanocobalamin) should not be used with other semaglutide-containing products or other GLP-1 receptor agonist medicines.

Important Safety Information

What is the most important information I should know about Semaglutide
(Ozempic, Wegovy, or compounded semaglutide/cyanocobalamin?

May cause serious side effects, including:

Possible thyroid tumors, including cancer. Tell your healthcare provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. In studies with rodents, Semaglutide(Ozempic, Wegovy, Semaglutide/cyanocobalamin) and medicines that work like semaglutide (Ozempic, Wegovy, Semaglutide/cyanocobalamin) caused thyroid tumors, including thyroid cancer. It is not known if semaglutide will cause thyroid tumors or a type of thyroid cancer called medullary thyroid carcinoma (MTC) in people
Do not use semaglutide(Ozempic, Wegovy, Semaglutide/cyanocobalamin) if you or any of your family have ever had a type of thyroid cancer called medullary thyroid carcinoma (MTC) or if you have an endocrine system condition called Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)

Do not use semaglutide (Ozempic, Wegovy, or compounded
semaglutide/cyanocobalamin if:

you or any of your family have ever had a type of thyroid cancer called
medullary thyroid carcinoma (MTC) or if you have an endocrine system
condition called Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
you have had a serious allergic reaction to semaglutide or any of the
ingredients in semaglutide (Ozempic, wegovy, or compounded
semaglutide/cyanocobalamin.

Before using Semaglutide (Ozempic, Wegovy, or compounded
semaglutide/cyanocobalamin) tell your healthcare provider if you have any other medical conditions, including if you:

have or have had problems with your pancreas or kidneys
have type 2 diabetes and a history of diabetic retinopathy
have or have had depression, suicidal thoughts, or mental health issues
are pregnant or plan to become pregnant. Semaglutide (Ozempic, Wegovy,
Semaglutide/cyanocobalamin) may harm your unborn baby. You should stop
using semaglutide (Ozempic, Wegovy, Semaglutide/cyanocobalamin) 2
months before you plan to become pregnant
are breastfeeding or plan to breastfeed. It is not known if semaglutide
(Ozempic, Wegovy, Semaglutide/cyanocobalamin) passes into your breast
milk

Tell your healthcare provider about all the medicines you take, including
prescription and over-the-counter medicines, vitamins, and herbal supplements.
Semaglutide (Ozempic, Wegovy, compounded semaglutide/cyanocobalamin) may affect the way some medicines work and some medicines may affect the way semaglutide works. Tell your healthcare provider if you are taking other medicines to treat diabetes, including sulfonylureas or insulin. Semaglutide (Ozempic, Wegovy, or compounded Semaglutide/cyanocobalamin) slows stomach emptying and can affect medicines that need to pass through the stomach quickly.

What are the possible side effects of Semaglutide(Ozempic, Wegovy, or compounded Semaglutide/cyanocobalamin)?
Semaglutide (Ozempic, Wegovy, or compounded Semaglutide/cyanocobalamin) may cause serious side effects, including:

inflammation of your pancreas (pancreatitis). Stop using semaglutide
(Ozempic, Wegovy, or compounded Semaglutide/cyanocobalamin) and call
your healthcare provider right away if you have severe pain in your stomach
area (abdomen) that will not go away, with or without vomiting. You may feel
the pain from your abdomen to your back
gallbladder problems. Semaglutide (Ozempic, Wegovy, or compounded
Semaglutide/cyanocobalamin) may cause gallbladder problems, including
gallstones. Some gallstones may need surgery. Call your healthcare provider
if you have symptoms, such as pain in your upper stomach (abdomen), fever,
yellowing of the skin or eyes (jaundice), or clay-colored stools
increased risk of low blood sugar (hypoglycemia), especially those who also take medicines for diabetes such as insulin or sulfonylureas. This can be a serious side effect. Talk to your healthcare provider about how to recognize and treat low blood sugar and check your blood sugar before you start and while you take semaglutide (Ozempic, Wegovy, or compounded Semaglutide/cyanocobalamin) Signs and symptoms of low blood sugar may include dizziness or light-headedness, blurred vision, anxiety, irritability or mood changes, sweating, slurred speech, hunger, confusion or drowsiness, shakiness, weakness, headache, fast heartbeat, or feeling jittery
kidney problems (kidney failure). In people who have kidney problems,
diarrhea, nausea, and vomiting may cause a loss of fluids (dehydration),
which may cause kidney problems to get worse. It is important for you to
drink fluids to help reduce your chance of dehydration
serious allergic reactions. Stop using Semaglutide (Ozempic, Wegovy, or
compounded Semaglutide/cyanocobalamin) and get medical help right away,
if you have any symptoms of a serious allergic reaction, including swelling of
your face, lips, tongue, or throat; problems breathing or swallowing; severe
rash or itching; fainting or feeling dizzy; or very rapid heartbeat
change in vision in people with type 2 diabetes. Tell your healthcare
provider if you have changes in vision during treatment with Semaglutide
(Ozempic, Wegovy, or compounded Semaglutide/cyanocobalamin)
increased heart rate. Semaglutide (Ozempic, Wegovy, or compounded
Semaglutide/cyanocobalamin) can increase your heart rate while you are at
rest. Tell your healthcare provider if you feel your heart racing or pounding in
your chest and it lasts for several minutes
depression or thoughts of suicide. You should pay attention to any mental
changes, especially sudden changes in your mood, behaviors, thoughts, or
feelings. Call your healthcare provider right away if you have any mental
changes that are new, worse, or worry you

The most common side effects of Semaglutide (Ozempic, Wegovy, or compounded Semaglutide/cyanocobalamin) may include: nausea, diarrhea, vomiting, constipation, stomach (abdomen) pain, headache, tiredness (fatigue), upset stomach, dizziness, feeling bloated, belching, low blood sugar in people with type 2 diabetes, gas, stomach flu, heartburn, and runny nose or sore throat.

By signing below I am acknowledging I have read the above information regarding risks and side effects related to this medication. I do not personally have a history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome. I also state that I am not pregnant and do not plan to become pregnant.

Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature*

Date

Tirzepatide (Mounjaro, Zepbound, or compounded tirzepatide with niacinamide):

Full medication information can be found at the following link:
Mounjaro & Zepbound:
https://tirzepatide.lilly.com/?gad_source=1&gclid=CjwKCAjwhIS0BhBqEiwADAUhc8iC8u
2SVPrK5Cbx6nZ_EEI7ye-7Osg8uBlpUFSciVMzNv9S3qiBTxoCYv8QAvD_BwE#identify
AuthenticMedicine

Compounded Tirzepatide/Niacinamide from Empower Pharmacy:
https://www.empowerpharmacy.com/compounding-pharmacy/tirzepatide-niacinamide-inj
ection/

SAFETY SUMMARY WITH WARNINGS

Warnings - Tirzepatide (Mounjaro, Zepbound, or compounded tirzepatide with
niacinamide): may cause tumors in the thyroid, including thyroid cancer. Watch for
possible symptoms, such as a lump or swelling in the neck, hoarseness, trouble
swallowing, or shortness of breath. If you have any of these symptoms, tell your
healthcare provider.

Do not use Tirzepatide (Mounjaro, Zepbound, or compounded tirzepatide with
niacinamide) if you or any of your family have ever had a type of thyroid cancer called medullary thyroid carcinoma (MTC).
Do not use Tirzepatide (Mounjaro, Zepbound, or compounded tirzepatide with
niacinamide) if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
Do not use Tirzepatide (Mounjaro, Zepbound, or compounded tirzepatide with
niacinamide) if you are allergic to it or any of the ingredients in Tirzepatide
(Mounjaro, Zepbound, or compounded tirzepatide with niacinamide).

Serious side effects, including:

Inflammation of the pancreas (pancreatitis). Stop using Tirzepatide (Mounjaro, Zepbound, or compounded tirzepatide with niacinamide) and call your healthcare provider right away if you have severe pain in your stomach area (abdomen) that will not go away, with or without vomiting. You may feel the pain from your abdomen to your back.
Low blood sugar (hypoglycemia). Your risk for getting low blood sugar may be higher if you use Tirzepatide (Mounjaro, Zepbound, or compounded tirzepatide with niacinamide) with another medicine that can cause low blood sugar, such as a
sulfonylurea or insulin. Signs and symptoms of low blood sugar may include
dizziness or light-headedness, sweating, confusion or drowsiness, headache, blurred vision, slurred speech, shakiness, fast heartbeat, anxiety, irritability, or mood changes, hunger, weakness and feeling jittery.
Serious allergic reactions. Stop using Tirzepatide (Mounjaro, Zepbound, or
compounded tirzepatide with niacinamide) and get medical help right away if you have any symptoms of a serious allergic reaction, including swelling of your face, lips, tongue or throat, problems breathing or swallowing, severe rash or itching, fainting or feeling dizzy, and very rapid heartbeat.
Kidney problems (kidney failure). In people who have kidney problems, diarrhea, nausea, and vomiting may cause a loss of fluids (dehydration), which may cause kidney problems to get worse. It is important for you to drink fluids to help reduce your chance of dehydration.
Severe stomach problems. Stomach problems, sometimes severe, have been
reported in people who use Tirzepatide (Mounjaro, Zepbound, or compounded
tirzepatide with niacinamide). Tell your healthcare provider if you have stomach
problems that are severe or will not go away.
Changes in vision. Tell your healthcare provider if you have changes in vision during treatment with Tirzepatide (Mounjaro, Zepbound, or compounded tirzepatide with niacinamide).
Gallbladder problems. Gallbladder problems have happened in some people who use Tirzepatide (Mounjaro, Zepbound, or compounded tirzepatide with niacinamide). Tell your healthcare provider right away if you get symptoms of gallbladder problems, which may include pain in your upper stomach (abdomen), fever, yellowing of skin or eyes (jaundice), and clay-colored stools.
Changes in vision in patients with type 2 diabetes. Tell your healthcare provider if you have changes in vision during treatment with Zepbound.
Depression or thoughts of suicide. You should pay attention to changes in your
mood, behaviors, feelings or thoughts. Call your healthcare provider right away if you have any mental changes that are new, worse, or worry you.

Common side effects

The most common side effects of Tirzepatide (Mounjaro, Zepbound, or compounded tirzepatide with niacinamide) include nausea, diarrhea, decreased appetite, vomiting, constipation, indigestion, and stomach (abdominal) pain. These are not all the possible side effects of Tirzepatide (Mounjaro, Zepbound, or compounded tirzepatide with niacinamide). Talk to your healthcare provider about any side effect that bothers you or doesn’t go away.

Before using Tirzepatide (Mounjaro, Zepbound, or compounded tirzepatide with
niacinamide):

- Discuss with your provider if you plan to become pregnant. Tirzepatide (Mounjaro, Zepbound, or compounded tirzepatide with niacinamide) can weaken the efficacy of your birth control pills.

Review these questions with your healthcare provider:

Do you have other medical conditions, including problems with your pancreas or kidneys, or severe problems with your stomach, such as slowed emptying of your stomach (gastroparesis) or problems digesting food?
Do you take other diabetes medicines, such as insulin or sulfonylureas?
Do you have a history of diabetic retinopathy?
Are you pregnant, plan to become pregnant, breastfeeding, or plan to breastfeed? It is not known if Mounjaro will harm your unborn baby or pass into your breast milk.
Do you take any other prescription medicines or over-the-counter drugs, vitamins, or herbal supplements?

By signing below I am acknowledging I have read the above information regarding risks and side effects related to this medication. I also state that I am not pregnant and do not plan to become pregnant.

Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature*

Date

Metformin:

Full medication information can be found by clicking this link:
https://www.drugs.com/metformin.html

Metformin is used to treat high blood sugar levels that are caused by a type of diabetes mellitus or sugar diabetes called type 2 diabetes. With this type of diabetes, insulin produced by the pancreas is not able to get sugar into the cells of the body where it can work properly. Using metformin alone, with a type of oral antidiabetic medicine called a sulfonylurea, or with insulin, will help to lower blood sugar when it is too high and help restore the way you use food to make energy.

Before Using

In deciding to use a medicine, the risks of taking the medicine must be weighed against the good it will do. This is a decision you and your doctor will make. For this medicine, the following should be considered:

Allergies

Tell your doctor if you have ever had any unusual or allergic reaction to this medicine or any other medicines. Also tell your health care professional if you have any other types of allergies, such as to foods, dyes, preservatives, or animals. For non-prescription products, read the label or package ingredients carefully.

Pediatric

Appropriate studies performed to date have not demonstrated pediatric-specific
problems that would limit the usefulness of metformin oral solution, extended-release oral suspension, and tablets in children 10 to 16 years of age. However, safety and efficacy of metformin extended-release tablets in the pediatric population have not been established.

Geriatric

Although appropriate studies on the relationship of age to the effects of metformin have not been performed in the geriatric population, geriatric-specific problems are not expected to limit the usefulness of metformin in the elderly. However, elderly patients are more likely to have age-related kidney problems, which may require caution in patients receiving metformin. This medicine is not recommended in patients 80 years of age and older who have kidney problems.

Breastfeeding

There are no adequate studies in women for determining infant risk when using this medication during breastfeeding. Weigh the potential benefits against the potential risks before taking this medication while breastfeeding.

Drug Interactions

Please review full medication interactions by clicking this link: https://www.drugs.com/metformin.html

Precautions

It is very important that your doctor check your or your child's progress at regular visits, especially during the first few weeks that you take this medicine. Blood and urine tests may be needed to check for unwanted effects.

This medicine may interact with the dye used for an X-ray or CT scan. Your doctor
should advise you to stop taking it before you have any medical exams or diagnostic tests that might cause less urine output than usual. You may be advised to start taking the medicine again 48 hours after the exams or tests if your kidney function is tested and found to be normal.

Make sure any doctor or dentist who treats you knows that you are using this medicine. You may need to stop using this medicine several days before having surgery or medical tests.

It is very important to carefully follow any instructions from your health care team about:

Alcohol—Drinking alcohol may cause severe low blood sugar. Discuss this
with your health care team.
Other medicines—Do not take other medicines unless they have been
discussed with your doctor. This especially includes nonprescription
medicines such as aspirin, and medicines for appetite control, asthma, colds,
cough, hay fever, or sinus problems.
Counseling—Other family members need to learn how to prevent side effects
or help with side effects if they occur. Also, patients with diabetes may need
special counseling about diabetes medicine dosing changes that might occur
with lifestyle changes, such as changes in exercise or diet. Counseling on
birth control and pregnancy may be needed because of the problems that can
occur in pregnancy for patients with diabetes.
Travel—Keep a recent prescription and your medical history with you. Be
prepared for an emergency as you would normally. Make allowances for
changing time zones and keep your meal times as close as possible to your
usual meal times.
In case of emergency—There may be a time when you need emergency help
for a problem caused by your diabetes. You need to be prepared for these
emergencies. It is a good idea to wear a medical identification (ID) bracelet or neck chain at all times. Also, carry an ID card in your wallet or purse that says that you have diabetes and a list of all of your medicines.

Under certain conditions, too much metformin can cause lactic acidosis. The symptoms of lactic acidosis are severe and quick to appear, and usually occur when other health problems not related to the medicine are present and are very severe, such as a heart attack or kidney failure. Symptoms of lactic acidosis include abdominal or stomach discomfort, decreased appetite, diarrhea, fast or shallow breathing, a general feeling of discomfort, severe muscle pain or cramping, and unusual sleepiness, tiredness, or weakness.

If symptoms of lactic acidosis occur, you should get immediate emergency medical help.

This medicine may cause some premenopausal women who do not have regular
monthly periods to ovulate. This can increase the chance of pregnancy. If you are a
woman of childbearing potential, you should discuss birth control options with your
doctor.

This medicine may cause hypoglycemia (low blood sugar). This is more common when this medicine is taken together with certain medicines. Low blood sugar must be treated before it causes you to pass out (unconsciousness). People feel different symptoms of low blood sugar. It is important that you learn which symptoms you usually have so you can treat it quickly. Talk to your doctor about the best way to treat low blood sugar.

Hyperglycemia (high blood sugar) may occur if you do not take enough or skip a dose of your medicine, overeat or do not follow your meal plan, have a fever or infection, or do not exercise as much as usual. High blood sugar can be very serious and must be treated right away. It is important that you learn which symptoms you have in order to treat it quickly. Talk to your doctor about the best way to treat high blood sugar.

High blood sugar may occur if you do not exercise as much as usual, have a fever or infection, do not take enough or skip a dose of your diabetes medicine, or overeat or do not follow your meal plan.

Side Effects

Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.

Check with your doctor immediately if any of the following side effects occur:

More common

Abdominal or stomach discomfort
cough or hoarseness
decreased appetite
diarrhea
fast or shallow breathing
fever or chills
general feeling of discomfort
lower back or side pain
muscle pain or cramping
painful or difficult urination
sleepiness

Less common

Anxiety
blurred vision
chest discomfort
cold sweats
coma
confusion
cool, pale skin
depression
difficult or labored breathing
dizziness
fast, irregular, pounding, or racing heartbeat or pulse
feeling of warmth
headache
increased hunger
increased sweating
nausea
nervousness
nightmares
redness of the face, neck, arms, and occasionally, upper chest
seizures
shakiness
slurred speech
tightness in the chest
unusual tiredness or weakness

Rare

Behavior change similar to being drunk
difficulty with concentrating
drowsiness
lack or loss of strength
restless sleep
unusual sleepiness

Some side effects may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. Also, your health care professional may be able to tell you about ways to prevent or reduce some of these side effects. Check with your health care professional if any of the following side effects continue or are bothersome or if you have any questions about them:

More common

Acid or sour stomach
belching
bloated
excess air or gas in the stomach or intestines
full feeling
heartburn
indigestion
loss of appetite
metallic taste in the mouth
passing of gas
stomachache
stomach upset or pain
vomiting
weight loss

Less common

Abnormal stools
bad, unusual, or unpleasant (after) taste
change in taste
difficulty with moving
discoloration of the fingernails or toenails
flu-like symptoms
joint pain
rash
sneezing
stuffy or runny nose
swollen joints

Other side effects not listed may also occur in some patients. If you notice any other effects, check with your healthcare professional.

By signing below I am acknowledging I have read the above information regarding risks and side effects related to this medication. I also state that I am not pregnant and do not plan to become pregnant.

Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature*

Date

Phentermine (Adipex):
Full medication information can be found on
the website at:
https://www.drugs.com/phentermine.html

Phentermine is used to speed weight loss in overweight people. It is used
together with diet and exercise to treat obesity, especially in people with risk
factors such as high blood pressure, high cholesterol, or diabetes.

Phentermine is similar to an amphetamine. It stimulates the central nervous
system (nerves and brain), which increases your heart rate and blood pressure
and decreases your appetite.

Warnings

Do not use phentermine if you are pregnant or breastfeeding a baby.

You should not use phentermine if you have glaucoma, overactive thyroid, severe
heart problems, uncontrolled high blood pressure, advanced coronary artery
disease, extreme agitation, or a history of drug abuse.

Do not use this medicine if you have used an MAO inhibitor in the past 14 days,
such as isocarboxazid, linezolid, methylene blue injection, phenelzine, rasagiline,
selegiline, or tranylcypromine. A dangerous drug interaction could occur.

Before taking this medicine

You should not use phentermine if you are allergic to it, or if you have:

a history of heart disease (coronary artery disease, heart rhythm problems,
congestive heart failure, stroke);
severe or uncontrolled high blood pressure;
overactive thyroid;
glaucoma;
extreme agitation or nervousness;
a history of drug abuse; or
if you take other diet pills.

Do not use phentermine if you have used an MAO inhibitor in the past 14 days. A
dangerous drug interaction could occur. MAO inhibitors include isocarboxazid,
linezolid, methylene blue injection, phenelzine, rasagiline, selegiline, tranylcypromine, and others.

Weight loss during pregnancy can harm an unborn baby, even if you are
overweight. Do not use phentermine if you are pregnant. Tell your doctor right
away if you become pregnant during treatment.

You should not breast-feed while using this medicine.

To make sure this medicine is safe for you, tell your doctor if you have:

heart disease or coronary artery disease;
a heart valve disorder;
high blood pressure;
diabetes (your diabetes medication dose may need to be adjusted); or
kidney disease.

Phentermine side effects

Get emergency medical help if you have signs of an allergic reaction to
phentermine: hives; difficult breathing; swelling of your face, lips, tongue, or
throat.

Phentermine may cause serious side effects. Call your doctor at once if you
have:

feeling short of breath, even with mild exertion;
chest pain, feeling like you might pass out;
swelling in your ankles or feet;
pounding heartbeats or fluttering in your chest;
tremors, feeling restless, trouble sleeping;
unusual changes in mood or behavior; or
increased blood pressure - severe headache, blurred vision, pounding in
your neck or ears, anxiety, nosebleed.

Common side effects of phentermine may include:

itching;
dizziness/headache;
dry mouth;
unpleasant taste;
diarrhea;
constipation;
stomach pain; or
increased or decreased interest in sex.

This is not a complete list of side effects and others may occur. Call your doctor
for medical advice about side effects. You may report side effects to FDA at
1-800-FDA-1088.

Phentermine side effects (more detail)

What other drugs will affect phentermine?

Taking phentermine together with other diet medications such as fenfluramine
(Phen-Fen) or dexfenfluramine (Redux) can cause a rare fatal lung disorder
called pulmonary hypertension. Do not take phentermine with any other diet
medications without your doctor's advice.

Many drugs can interact with phentermine. This includes prescription and
over-the-counter medicines, vitamins, and herbal products. Not all possible
interactions are listed here. Tell your doctor about all your current medicines and
any medicine you start or stop using.

By signing below I am acknowledging I have read the above information regarding risks and side effects related to this medication. I also state that I am not pregnant and do not plan to become pregnant.

Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature*

Date

Qysimia (Phentermine /topiramate):

Full medication information can be found by visiting their website at:
https://qsymia.com/?utm_source=google&utm_medium=cpc&gad_so
urce=1&gclid=CjwKCAjwhIS0BhBqEiwADAUhc3ZFsIV6NrEkjPcmJG-3
dI8tDsw4qLqOiYqf_4u1FHTM2MtQ8MejIxoCqcsQAvD_BwE

Important Safety Information

Do not take Qsymia if you are pregnant, planning to become pregnant, or become
pregnant during Qsymia treatment; have glaucoma; have thyroid problems
(hyperthyroidism); are taking certain medicines called monoamine oxidase inhibitors
(MAOIs) or have taken MAOIs in the past 14 days; are allergic to topiramate,
sympathomimetic amines such as phentermine, or any of the ingredients in Qsymia.
See the end of the Medication Guide for a complete list of ingredients in Qsymia.

QSYMIA CAN CAUSE SERIOUS SIDE EFFECTS, INCLUDING:

Birth defects (cleft lip/cleft palate). If you take Qsymia during pregnancy, your baby has a higher risk for birth defects called cleft lip and cleft palate. These defects can begin early in pregnancy, even before you know you are pregnant. Patients who are pregnant must not take Qsymia. Patients who can become pregnant should have a pregnancy test before taking Qsymia and every month while taking Qsymia and use effective birth control (contraception) consistently while taking Qsymia. Talk to your healthcare provider about how to prevent pregnancy.

If you become pregnant while taking Qsymia, stop taking Qsymia immediately, and tell
your healthcare provider right away. Healthcare providers and patients should report all
cases of pregnancy to FDA MedWatch at 1-800-FDA-1088, and the Qsymia Pregnancy
Surveillance Program at 1-888-998-4887.

Qsymia may slow the increase in height in children 12 years and older.

Increases in heart rate. Qsymia can increase your heart rate at rest. Your healthcare
provider should check your heart rate while you take Qsymia. Tell your healthcare
provider if you experience, while at rest, a racing or pounding feeling in your chest
lasting several minutes when taking Qsymia.

Visual field defects (independent of elevated intraocular pressure) have been reported
in clinical trials and in postmarketing experience in patients receiving topiramate. In
clinical trials, most of these events were reversible after topiramate discontinuation. If
visual problems occur at any time during treatment, consider discontinuing Qsymia.

Suicidal thoughts or actions. Topiramate, an ingredient in Qsymia, may cause you to
have suicidal thoughts or actions. Call your healthcare provider right away if you have
any of these symptoms, especially if they are new, worse, or worry you: thoughts about suicide or dying; attempts to commit suicide; new or worse depression; new or worse anxiety; feeling agitated or restless; panic attacks; trouble sleeping (insomnia); new or worse irritability; acting aggressive, being angry, or violent; acting on dangerous impulses; an extreme increase in activity or talking (mania); other unusual changes in behavior or mood.

Serious eye problems, which include any sudden decrease in vision, with or without eye
pain and redness or a blockage of fluid in the eye causing increased pressure in the eye
(secondary angle closure glaucoma). These problems can lead to permanent vision loss
if not treated. Tell your healthcare provider right away if you have any new eye symptoms.

Qsymia may cause a severe rash with blisters and peeling skin, especially around the
mouth, nose, eyes, and genitals (Stevens-Johnson Syndrome). Qsymia may also cause
a rash with blisters and peeling skin over much of the body that may be life threatening
(Toxic Epidermal Necrolysis). Call your healthcare provider right away if you develop a
skin rash or blisters.

COMMON SIDE EFFECTS OF QSYMIA IN ADULTS INCLUDE:

Numbness or tingling in the hands, arms, feet, or face (paraesthesia); dizziness;
changes in the way foods taste or loss of taste (dysgeusia); trouble sleeping (insomnia); constipation; and dry mouth.

COMMON SIDE EFFECTS OF QSYMIA IN CHILDREN 12 YEARS OLD AND OLDER INCLUDE:

Depression, dizziness, joint pain, fever, flu, and ankle sprain.

POSSIBLE SIDE EFFECTS OF QSYMIA INCLUDE:

Mood changes and trouble sleeping. Qsymia may cause depression or mood problems,
and trouble sleeping. Tell your healthcare provider if symptoms occur.

Concentration, memory, and speech difficulties. Qsymia may affect how you think and
cause confusion, problems with concentration, attention, memory or speech. Tell your
healthcare provider if symptoms occur.

Increases of acid in bloodstream (metabolic acidosis). If left untreated, metabolic
acidosis can cause brittle or soft bones (osteoporosis, osteomalacia, osteopenia),
kidney stones, can slow the rate of growth in children, and may possibly harm your baby if you are pregnant. Metabolic acidosis can happen with or without symptoms.
Sometimes people with metabolic acidosis will: feel tired, not feel hungry (loss of
appetite), feel changes in heartbeat, or have trouble thinking clearly. Your healthcare
provider should do a blood test to measure the level of acid in your blood before and
during your treatment with Qsymia.

Low blood sugar (hypoglycemia) in people with type 2 diabetes mellitus who also take
medicines used to treat type 2 diabetes mellitus. Weight loss can cause low blood sugar
in people with type 2 diabetes mellitus who also take medicines used to treat type 2
diabetes mellitus (such as insulin or sulfonylureas). You should check your blood sugar
before you start taking Qsymia and while you take Qsymia.

High blood pressure medicines. If you are taking medicines for your blood pressure,
your doctor may need to adjust these medicines while taking Qsymia.

Central Nervous System (CNS) side effects. The use of prescription sleep aids, anxiety
medicines, or drinking alcohol with Qsymia may cause an increase in CNS symptoms
such as dizziness and light-headedness. Do not drink alcohol with Qsymia.

Possible seizures if you stop taking Qsymia too fast. Seizures may happen in people
who may or may not have had seizures in the past if you stop Qsymia too fast. Your
healthcare provider will tell you how to stop taking Qsymia slowly.

Kidney stones. Drink plenty of fluids when taking Qsymia to help decrease your
chances of getting kidney stones. If you get severe side or back pain, and/or blood in
your urine, call your healthcare provider.

Decreased sweating and increased body temperature (fever). People should be
watched for signs of decreased sweating and fever, especially in hot temperatures.
Some people may need to be hospitalized for this condition.

Qsymia capsules contain the inactive ingredient FD&C Yellow No. 5 (tartrazine) which
can cause allergic-type reactions (including bronchial asthma) in certain people,
especially people who also have an allergy to aspirin.

Tell your healthcare provider if you have any side effect that bothers you or does not go away. These are not all of the possible side effects of Qsymia. For more information,
ask your healthcare provider or pharmacist.

By signing below I am acknowledging I have read the above information regarding risks and side effects related to this medication. I also state that I am not pregnant and do not plan to become pregnant.

Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature*

Date

Hormone Replacement Therapy:

I, the above named patient, authorize and give my Informed Consent for staff at 4You LLC for the administration of hormone replacement therapy.

Expected Benefits of Hormone Replacement Therapy:

Expected benefits include control of symptoms associated with declining hormone levels.
Possible benefits of this therapy may help prevent, reduce or control physical diseases and dysfunction associated with declining hormone levels, through hormonal replacement.
I have been fully informed, and I am satisfied with my understanding, that this treatment may be viewed by the medial community as new, controversial, and unnecessary by the Food and Drug Administration.
I understand that my healthcare provider cannot guarantee any health benefits or that there will be no harm from the use of hormone replacement therapy.

Risks and Side Effects of Hormone Replacement Therapy:

Some of the following risks/adverse reactions are derived from the official Food and Drug Administration “FDA” labeling requirements for these drugs, for therapeutic drug levels in the blood stream. My healthcare provider may prescribe these medications at dosages designed to achieve physiologic levels of hormones in my blood stream or urine generally associated with those of a 20-35 years-old person and would be within the “normal” or “average” blood concentrations of that age group.
• General
I understand that the general risks of this proposed therapy may include, but are not limited to, bruising, soreness or pain, and possible infection for hormones administered by injection.
• I understand that there are risks (both known and unknown) to any medical procedure, treatment and therapy, and that it is not possible to guarantee or give assurance of a successful result. I acknowledge and accept these known and unknown general risks.

Testosterone:
• A prescription hormone, given by injection, transdermal cream or patch.
Risk of testosterone replacement include but are not limited to: stimulation of benign and malignant prostate tumor. Testosterone replacement is contraindicated in patients with known prostate cancer.
Side effects of testosterone replacement may include but are not limited to: an increase in the red blood cells, determined by periodic measuring of your red blood. It is not a common occurrence and generally poses no health risk; it can be corrected by donating blood or with a therapeutic phlebotomy. Male pattern baldness, gynecomastia (breast enlargement), diminished sperm production and a reduction in the size of the testicles may develop in men. Testosterone replacement may reduce insulin requirements in insulin-dependent diabetics. Older male patients may be at a slightly increased risk for the development of prostate enlargement when replacing testosterone. The concurrent use of testosterone with corticosteroids may enhance edema (fluid retention) formation. Edema may be a complication with testosterone replacement in patients with pre-existing cardiac, renal, or hepatic disease. It is not known whether testosterone replacement therapy will increase the risk for prostate cancer.
The most common immediate side effects (occurring in approximately no more than 6% of users) include but are not limited to: acne. application site reaction, headache, hypertension (high blood pressure), abnormal liver function tests, and non-cancerous prostate disorder. Other side effects may include greasy hair and skin, a strong body odor, and aggressiveness.

Estrogen:
• A prescription hormone, given by injection, orally or by transdermal cream or patch.
Risks associated with estrogen replacement include, but are not limited to: heart attacks, blood clot formation, gallstones, increased risk of uterine cancer (if progesterone is not administered with concurrently) and fibroid tumors. The Women’s Health Initiative study demonstrated increased risk when estrogen replacement is initiated 10 or more years after menopause.

Estrogen replacement is not recommended in women with a history of the following conditions: breast or uterine cancer, phlebitis and blood clots, gall bladder disease, uterine fibroma, and liver disease.
Side effects may include, but are not limited to: increased body fat, fluid retention, uterine bleeding, depression, headaches, impaired glucose tolerance, and aggravation of migraines.

Progesterone:
• A prescription hormone, given orally or by transdermal cream.
Risks of progesterone replacement include but are not limited to: Progestins are not the same as natural progesterone. Progestins may cancel the protective effect of estradiol and promote constriction of the coronary arteries to a significant degree. Natural progesterone, on the other hand, may protect the endometrium, preserve the beneficial effects of estrogen on the cardiovascular system and exert no negative effects on the blood vessels that supply your heart. Progestins may cause birth defects, damage to nerve cells, blood clots, and breast cancer. Side effects of progesterone replacement may include but are not limited to: nipple or breast tenderness, drowsiness, fluid retention, slight dizziness, anxiety, difficult sleeping, depression, acne, rashes, hot flashes, appetite increases and weight gain.

Thyroid Hormone:
• A prescription hormone taken by mouth.
Risks/adverse reactions include but are not limited to: palpitations and rapid heart rate, heart arrhythmias, excitability, increased metabolism. Cardiac sensitivity is a contraindication to thyroid replacement therapy. Excess amounts may increase the risk for osteoporosis in some people and suppress the body’s own ability to manufacture its own thyroid hormone.
Side effects may include, but are not limited to: sleep disturbances, fine trembling of fingers, excessive hunger and thirst, sweating, anxiety, and headaches.

Dehydroepiandrosterone- DHEA:
• DHEA is classified as a dietary supplement, given by mouth or by transdermal cream.
Risks of DHEA replacement include but are not limited to: worsening of certain cancers and should be avoided in men with existing prostate cancer and in women with breast cancer. DHEA replacement is not generally recommended in adults under age 35. Side effects of DHEA replacement are generally dose related and may include but are not limited to: acne or oily skin, hair growth on the face, arms and legs, acne in women, and prostate enlargement in men male pattern baldness, decreased HDL cholesterol, fatigue, mood changes, weight gain and insomnia.

Melatonin:
• A non-prescription hormone given by mouth.
Risks of Melatonin replacement include but are not limited to: nighttime exacerbation of asthma. It should be used cautiously when treating some autoimmune diseases and leukemia, Hodgkin’s disease or lymphoma.
Side effects of Melatonin replacement may include, but are not limited to: sleep disorders, bizarre dreams, headache, fatigue, stomach discomfort, and suppression of male sex drive.

Pregnenolone:
• A non-prescription hormone given by mouth.
Risks with pregnenolone replacement include but are not limited to: exacerbation of various cancers and should be avoided in those with cancer of the prostate, breast or uterus. Very high doses may cause cardiac arrhythmias.
Side effects of Pregnenolone replacement may include, but are not limited to: headaches, bloating, menstrual irregularities, heartburn, acne, agitation, sedation, rash and flushing.
Alternatives to Hormone Replacement Therapy:
I understand the reasonable alternatives to hormone replacement therapy, which include:

Leaving the hormone levels as they are and doing nothing. Risks may include but are not limited to:
experiencing symptoms of hormone deficiency, and increased risk for aging-related diseases or dysfunction resulting from declining hormone levels. This alternative may result in the need to treat diseases or dysfunction associated with declining hormone levels as they appear clinically.
Treating the symptoms of declining hormone levels as they develop with non-hormonal therapies. Risks may include but are not limited to: increased risk for aging-related diseases resulting from declining hormone levels.
My Compliance Obligation While Receiving Hormone Replacement Therapy:
I agree to comply with the proposed treatment and therapy as prescribed, including the fact that I may be responsible for injecting, taking by mouth, applying to my skin, or administrating the hormone(s) that may be prescribed to me, and consent to periodic monitoring, when requested, which may include:
o Laboratory monitoring of blood or urine chemistries and hormone levels o Physical examinations
o Regular screening evaluations
I agree to notify you regarding all signs or symptoms of possible reactions to my therapy.
I agree to comply with all other healthy lifestyle activities that have been individually recommended for me. I have completely disclosed my medical history, including prescription and non-prescription medications that I am currently taking or plan to take during my treatment, as well as any other
over-the- counter medications, recreational drugs or social substances, herbs, extracts, and other dietary supplements to you. I agree to comply with the recommendations regarding the continuation of these preparations.
In the future I will receive recommendations in advance from you before stopping any prescribed therapeutic regimens or taking additional preparations that are not recommended by you.
I certify that I am under the care of a physician(s) for any and all other medical conditions

Research and Economic Interests
• I understand that the prescribing practitioner is not engaged in any personal research and has no economic interests unrelated to my immediate care or treatment that may affect the physician’s choice of treatment or medical judgment.
I certify that I have been given the opportunity to ask any and all questions I have concerning the proposed treatment, and I received all requested information and all questions were answered. I fully understand that I have the right to not consent to hormone replacement therapy. I believe I have adequate knowledge upon which to base an informed consent.
I do now attest to reading and fully understanding this form and the contents and clinical meanings of such and discussing these procedures with my healthcare provider and consent to this treatment, and hereby affix my signature to this authorization for this proposed long-term treatment. I have been given a copy of this consent form, and I understand fully any and all of the possibly represented implications and meanings of its writing and expectations.

Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature*

Date

I do not plan to become pregnant and will take additional precautions to ensure I do not become pregnant while undergoing treatment. I will notify my provider immediately if I plan or become pregnant. By signing below you are acknowledging the risk.

Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature*

Date

Sign here acknowledging you have reviewed the detailed medication risks and contraindications provided and agree to starting treatment. The provide/ nurse practitioner, the registered nurse, as well as 4You LLC is not responsible for any adverse side effects associated with the medications and you are giving consent for treatment by signing below.

Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature*

Date