Patient Acknowledgement 

 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 a 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, telehealth, or in person to review progress, benefits, and any

• Side effects/complications.