Patient Acknowledgement Form

• I understand the purpose of the GLP 1 injections and why it is recommended.

• I understand the potential benefits and the possible risks, including rare but serious complications.

• I was given the opportunity to ask questions and have them answered to my satisfaction.

• I understand that I may decline treatment unless this injection is required as part of an emergency or medically necessary procedure.

While taking GLP 1 medications it was recommended to:

-Eat fibrous diet

-Eat small, high protein meals

-Exercise daily

-Drink water, (minimum 32 oz daily )

-Have a bowel movement, inform practitioner if unable to day 3

-Limit alcohol

-A follow up apt/discussion via text, tele health or in person to review progress, benefits, and any side effects/complications.

Type Name