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GLP-1 Medication Disclaimer, Risks & Treatment Acknowledgment


Purpose & Scope of Care

Bastien Wellness Medicine PLLC provides medically guided weight loss support. These services are not a substitute for primary medical care.

We are not your treating physician for unrelated health concerns.

You must continue care with your primary healthcare provider and notify them of your participation in GLP-1 therapy.


Medication Overview

Medications used in this program may include:

• Semaglutide and Tirzepatide – GLP-1 receptor agonists that may support weight loss by increasing insulin secretion, reducing appetite, and delaying gastric emptying.

• These medications are dispensed through a compounding pharmacy (not brand-name Ozempic®, Wegovy®, Zepbound®, or Mounjaro®). Compounded medications are not FDA-approved, though they contain the same active pharmaceutical ingredient.

• I understand that I have access to branded medications and may discuss this option with the consulting provider.


Adjunctive Support (sometimes added):

• Glycine – may support anti-inflammatory effects, gut health, sleep quality, stress management, and insulin sensitivity.

• Vitamin B3 – may help reduce injection site irritation, and boost energy.

Potential Side Effects

Common:

• Nausea, vomiting, diarrhea, constipation

• Headache, dizziness, fatigue

• Hypoglycemia (especially with insulin or sulfonylureas)

• Abdominal pain, indigestion, injection site reactions

• Appetite loss


Less common but serious risks:

• Pancreatitis (severe abdominal pain ± vomiting)

• Gallbladder issues (stones, inflammation)

• Thyroid tumors (contraindicated with MTC or MEN 2 history)

• Delayed gastric emptying (may affect absorption of other medications, e.g., oral contraceptives)

• Allergic reactions or anaphylaxis (rare)


Patient Responsibilities

I agree to:

• Inform Bastien Wellness Medicine PLLC of all medications and health conditions.

• Inform Bastien Wellness Medicine PLLC of all changes for medications, health conditions, surgeries, or pregnancy(planned or unplanned).

• Notify my primary care provider (PCP) of my participation in GLP-1 therapy.

• Report adverse reactions promptly.

• Follow dosing, diet, exercise, and behavior recommendations.

• Stop treatment after 12 weeks if <5% of initial body weight is lost.

• Understand that weight regain after discontinuation is possible.

• Recognize that long-term treatment may be necessary for chronic obesity.

• Accept that inconsistent use may reduce effectiveness; alternative therapies may be suggested if progress plateaus.

Shipping & Medication Handling

• Medication must be refrigerated upon receipt.

• Updates will be provided via email/text. I am responsible for retrieving my package.

• Bastien Wellness Medicine PLLC is not liable for spoiled medications due to delayed retrieval or incorrect address.

• Ice packs may melt in transit, but potency is maintained.

• All sales are final – no refunds or returns once orders are placed.

Medication Expiration & Ordering Policy

• Expiration dates are set by the compounding pharmacy and cannot be altered or extended.

• Smaller vial sizes are recommended to reduce risk of expiration before use.

• Patients choosing larger vials do so at their own risk.

• Bastien Wellness Medicine PLLC is not responsible for expired medications.

Informed Consent

By signing below, I acknowledge that I have:

• Been informed of the risks, benefits, and alternatives to treatment.

• Been advised to continue care with my primary care provider.

• Been informed that rebound weight gain is possible after discontinuation.

• Been advised that ongoing treatment may be appropriate for long-term weight management.

• Read and understood all of the above information, and had the opportunity to ask questions.


I understand that the medical professionals affiliated with Bastien Wellness Medicine PLLC are providing consultation and medical guidance specifically related to weight loss and related wellness goals.

• They are not diagnosing or managing unrelated medical conditions.

• I remain responsible for ongoing care with my primary care physician or specialists.

• These services are limited in scope and not a substitute for comprehensive medical care.


I hereby release and hold harmless Bastien Wellness Medicine PLLC and its affiliates from any claims or liabilities arising from the use or misuse of this weight loss program, including but not limited to failure to seek or follow appropriate medical advice from my treating physician.

Acknowledgment & Signature

I Agree
I have read and fully understand this disclaimer and informed consent. I voluntarily agree to participate in GLP-1 therapy under the guidance of Bastien Wellness Medicine PLLC. 

January 23, 2026

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Contraindications
Do you have or have a family history of medullary thyroid cancer (MTC)*
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Do you have history of multiple endocrine neoplasia syndrome type 2 (MEN 2)*
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Are you pregnant, planning pregnancy within 2 months, or breastfeeding (safety not established)*
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Current or past medical condition(s):
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GLP-1 Goal
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How much weight do you want to lose? *
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


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 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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