Patient Consent Form

4. Dosing and Self-Administration Safety

Medication may be supplied in vials, syringes, pens, oral forms, or other delivery systems. Milligrams (mg), micrograms (mcg), milliliters (mL), and syringe units are not interchangeable. Using the wrong product, concentration, syringe amount, route, or frequency can cause overdose or serious harm.

• I will confirm the medication name, concentration, dose, syringe units or volume, route, frequency, storage requirements, and beyond-use or expiration date before every dose.
• I will not change, increase, decrease, combine, split, restart, or stop therapy without direction from the licensed medical provider.
• I will not share, sell, transfer, or give medication to another person.
• When instructions are unclear, I will not use the medication until I have contacted the prescribing provider, pharmacy, or licensed medical support.
• I am responsible for safe injection technique, needle and sharps disposal, prompt receipt and inspection of shipments, and proper storage. I will not use medication that appears damaged, leaking, contaminated, unusually colored, frozen, overheated, or expired until cleared by the pharmacy or provider.

5. Risks, Side Effects, and No Guarantee of Results

All prescription medications, compounded products, peptides, injections, hormone-related therapies, and telehealth-supported programs have risks. Results differ by person and depend on health history, genetics, nutrition, activity, sleep, stress, alcohol or substance use, adherence, other medications, and underlying conditions. No amount of weight loss, appetite reduction, muscle retention, recovery, energy, body-composition change, or other outcome is promised or guaranteed.

Possible general risks include nausea, vomiting, diarrhea, constipation, abdominal pain, indigestion, reflux, headache, fatigue, dizziness, dehydration, weakness, injection-site pain or infection, allergic reaction or anaphylaxis, blood-sugar changes, blood-pressure or heart-rate changes, medication interactions, mood or sleep changes, unknown long-term risks, hospitalization, disability, or death.

GLP-1 / GLP-1-GIP Risks

Additional potential risks include delayed stomach emptying, severe constipation, ileus or bowel obstruction, gallstones or gallbladder disease, pancreatitis, kidney injury, worsening gastroparesis, low blood sugar (especially with diabetes medication), increased heart rate or palpitations, vision changes or worsening diabetic retinopathy, excessive weight or muscle loss, hair loss, nutritional deficiencies, and possible thyroid-related risks. Patients with a personal or family history of medullary thyroid carcinoma or MEN2, or certain patients with prior pancreatitis, may not be appropriate candidates. These medications may affect oral medication absorption; tirzepatide may reduce oral contraceptive effectiveness during initiation and dose escalation. I will discuss contraception and medication interactions with the prescribing provider.

Peptide Risks

Many peptide uses are not FDA-approved and may have limited human clinical evidence. Potential risks include injection reactions, headache, nausea, fatigue, flushing, dizziness, changes in sleep, mood, appetite, glucose, blood pressure, heart rate, energy, hormones, fluid retention, joint discomfort, tingling, numbness, allergic reactions, interactions, and unknown short- or long-term effects. Peptides are not a substitute for diagnosis or treatment of disease, injury, or an emergency.

Hormone-Related Risks

When applicable, potential risks of TRT/HRT include acne, oily skin, hair changes, mood or libido changes, fluid retention, fertility changes, testicular shrinkage, menstrual changes, increased red blood cell count, cholesterol or blood-pressure changes, worsening sleep apnea, prostate concerns, blood clots, stroke, heart attack, and the need for ongoing labs and monitoring. Testosterone is a controlled substance and is subject to federal and state prescribing requirements.

6. Medical History, Laboratory Testing, Pregnancy, and Procedures

I will provide complete and truthful information about diagnoses, symptoms, allergies, surgeries, pregnancy status, family history, prescriptions, over-the-counter products, supplements, hormones, peptides, alcohol, and recreational substances. I will promptly report a new diagnosis, pregnancy, surgery, hospitalization, medication, or adverse reaction. Treatment may be delayed, changed, or stopped if information or requested laboratory testing is incomplete.

I will notify the provider immediately if I am pregnant, may be pregnant, am trying to conceive, or am breastfeeding. I will also notify the prescribing provider, surgeon, anesthesiologist, dentist, or procedural team before surgery, anesthesia, sedation, endoscopy, colonoscopy, or another procedure because GLP-1 and GLP-1/GIP drugs may delay stomach emptying. I will hold or change medication only under medical direction.

7. Telehealth and Electronic Communications

I consent to telehealth and remote communication by video, telephone, portal, online form, text message, and email for evaluation, follow-up, education, laboratory review, prescription coordination, billing, ordering, reordering, reminders, and support when appropriate. Telehealth may be limited by technology failures, incomplete information, lack of an in-person examination, delays, miscommunication, or privacy and security risks. The provider may require in-person care, testing, imaging, or specialist evaluation.

I will provide my accurate physical location during a telehealth encounter when requested. Care may be unavailable if the provider is not licensed or authorized where I am physically located. I may withdraw consent to telehealth, although doing so may prevent remote evaluation, prescribing, follow-up, or program support.

Routine email and text messaging may not be fully secure. I understand that messages may appear on my device, lock screen, phone bill, email account, or shared devices. I may request that sensitive details be limited and may change my communication preference by written notice. Electronic communication is not for emergencies.

8. Privacy Practices and HIPAA Acknowledgment

Sands Weight Loss & Wellness and participating providers will collect and use personal information that may include identification, contact information, medical history, medications, laboratory results, photographs, payment information, orders, communications, and a government-issued photo ID. Information may be used or shared as reasonably necessary for treatment, payment, healthcare operations, identity verification, telehealth, provider and pharmacy coordination, laboratory services, billing, payment processing, fraud prevention, legal compliance, patient support, and program administration.

HIPAA applies to covered healthcare providers, health plans, healthcare clearinghouses, and their business associates. Depending on the legal role of each organization, Sands Weight Loss & Wellness may act as an administrative service provider or business associate, while Guardian MD, Asher Health network providers, Open Loop providers, pharmacies, and laboratories may have separate privacy duties and may provide their own Notice of Privacy Practices. Nothing in this document reduces any privacy right I have under applicable federal or state law.

When HIPAA applies, my rights may include requesting access to or a copy of my records; requesting correction; requesting certain restrictions or confidential communications; receiving an accounting of certain disclosures; receiving notice following certain breaches; obtaining a paper copy of the applicable Notice of Privacy Practices; and filing a privacy complaint without retaliation. Some requests may be limited or denied as permitted by law.

Protected information may be disclosed without a separate authorization when permitted or required by law, including for treatment, payment, healthcare operations, public-health activities, health oversight, judicial or administrative proceedings, law enforcement, preventing a serious threat, workers compensation, or other legally permitted purposes. A separate written authorization will be obtained when required. I may revoke a separate authorization in writing, except to the extent action has already been taken in reliance on it.

Privacy questions or complaints may be directed to Sands Weight Loss & Wellness using the contact information published on our website. Privacy concerns involving a medical provider, pharmacy, laboratory, or other organization may also be directed to that organization.

9. Authorization to Contact Other Healthcare Providers

I may authorize the organizations involved in my program to contact my primary care provider, specialist, laboratory, hospital, or other healthcare provider and to request, receive, use, or disclose relevant information for treatment coordination, eligibility review, prescription safety, laboratory review, adverse-event follow-up, billing, or continuity of care. This authorization does not permit marketing use of my information. It expires one year after my signature or when my participation ends, whichever is later, unless a shorter period is required by law. I may revoke it in writing, except for actions already taken in reliance on it. Declining may limit care coordination or treatment eligibility.

12. Patient Responsibilities and Alternatives

I am responsible for providing accurate medical, identity, billing, shipping, and contact information; reading every label and instruction; following the provider plan; reporting side effects; maintaining primary and specialty care; completing requested labs; safeguarding medication; and seeking emergency care when necessary. Failure to do so may cause treatment delays, billing or shipping problems, loss of effectiveness, or serious harm.

Alternatives may include no treatment, lifestyle changes, nutrition or exercise programs, care from my primary care provider or specialist, commercially manufactured FDA-approved medications, in-person care, bariatric evaluation, or other medical or non-medical options. I may discuss alternatives with the prescribing provider before proceeding.

13. Assumption of Risk, Release, and Hold Harmless

I voluntarily accept the known and unknown risks of the program and understand that serious complications, hospitalization, disability, or death are possible even when uncommon. To the fullest extent permitted by applicable law, I release and hold harmless Sands Weight Loss & Wellness and its owners, employees, contractors, affiliates, agents, and representatives from claims arising from services outside its non-medical role, including medical decisions of independent licensed providers; pharmacy compounding, dispensing, fulfillment, or shipping; my misuse or self-administration of medication; failure to follow instructions or disclose information; telehealth or communication limitations; and billing, ordering, or reordering coordination. This provision does not waive rights or claims that cannot lawfully be waived, including claims based on conduct for which liability cannot be excluded under applicable law.

FINAL PATIENT ACKNOWLEDGMENT AND SIGNATURE

By signing below, I confirm that I have read this document, understand its contents, had the opportunity to ask questions, and voluntarily agree to participate. I understand that:

• Licensed medical providers - not Sands Weight Loss & Wellness - make all medical, prescribing, dosing, and treatment decisions.
• Some medications or peptides may be compounded, non-FDA-approved, and supported by limited clinical evidence.
• All treatments have possible side effects and unknown risks, and results are not guaranteed.
• I must follow the current prescription and label, ask before dosing when uncertain, and seek emergency care when appropriate.
• I consent to telehealth and the selected electronic communications described above.
• I acknowledge the privacy practices and applicable HIPAA rights described above.
• I accept the billing, cancellation, no-refund, and non-returnable medication policies.
• I voluntarily assume treatment risks and agree to the release and hold-harmless terms to the fullest extent allowed by law.

Optional / Applicability Acknowledgments