Mounjaro (Tirzepatide) Consent Form

Please read the following carefully before continuing with treatment. You will be asked to confirm that you have read and understood this before you can place an order.

What is Mounjaro?

Mounjaro (tirzepatide) is a GLP-1 receptor agonist approved for weight management. It works by regulating appetite, reducing hunger, and increasing fullness. It is used alongside a reduced-calorie diet and increased physical activity to support clinically supervised weight loss in eligible adults.

Potential Benefits

Weight loss may improve health issues related to excess weight, including high blood pressure, cholesterol, blood sugar levels, and overall physical health-related quality of life. However, individual results will vary and are not guaranteed.

Important Safety Information

Before starting or continuing Mounjaro, you must be aware of the following:

Treatment Suitability:
- You should not take Mounjaro if any of the following apply:
  - Under 18 or over 75
  - Pregnant, breastfeeding, or planning pregnancy
  - Personal or family history of medullary thyroid cancer (MTC)
  - History of pancreatitis, gallbladder disease, or severe gastrointestinal conditions
  - Severe liver or kidney disease
  - Concurrent treatment with insulin or other GLP-1 medications
  - Currently taking any medication known to cause weight gain

Side Effects May Include:
- Nausea, vomiting, diarrhoea, constipation
- Dizziness, headache, fatigue
- Less commonly: gallbladder problems, pancreatitis, thyroid concerns

Medication Interactions:
- Mounjaro may slow digestion and affect the absorption of other medications, including oral contraceptives.

Pregnancy Precautions:
- You must use effective contraception during treatment and for at least 1 month after stopping.
- A non-oral method is advised during the first 4 weeks of treatment and after each dose increase.

Monitoring and Responsibilities

- You must report any changes in your medical condition or medications to the prescribing team.
- If you experience any physical or emotional side effects, discontinue treatment and contact your prescriber immediately.
- You are encouraged to engage in regular follow-ups and check-ins. A consultation is available at any time should you wish to discuss your treatment.

Treatment Expectations

- Your dose may be increased gradually if appropriate.
- Weight loss results may plateau over time, and increasing your dose may not necessarily lead to greater weight loss if your appetite is already suppressed.
- If you do not lose at least 5% of your initial weight after 12 weeks at the full dose, treatment may be reconsidered.

Acknowledgement

By proceeding with treatment, you confirm:
- You have read and understood the above information
- You have had the opportunity to ask questions
- You consent to proceed with treatment under medical supervision
- You are aware of the potential risks, interactions, and responsibilities