Medical Weight Loss Informed Consent
Willow Health, LLC
Medical Weight Loss
Telehealth Informed Consent
By enrolling in medical weight loss services provided by Willow Health,
LLC, I acknowledge and agree to the following:
Nature of Services
I understand that Willow Health, LLC provides medical weight-loss
services via telehealth, which may include medical evaluation, review of health
history, ongoing clinical monitoring, and-when clinically appropriate-the
prescription of weight-loss medications, including GLP-1 receptor agonists
(such as semaglutide or tirzepatide).
I understand that participation in this program does not guarantee weight
loss or any specific outcome.
Telehealth
Disclosure
I understand that telehealth services have limitations compared to
in-person medical care. I acknowledge that physical examinations may be limited
and that some conditions may require in-person evaluation or emergency care. I
agree to seek in-person or emergency medical attention when necessary.
Medication Risks and
Side Effects
I understand that GLP-1 receptor agonist medications may cause side
effects, which can include, but are not limited to:
- Nausea
- Vomiting
- Diarrhea or constipation
- Abdominal pain or cramping
- Bloating or reflux symptoms
- Decreased appetite
- Fatigue or dizziness
- Injection site reactions
I understand that more serious but less common risks may include:
- Gallbladder disease (including gallstones)
- Pancreatitis
- Severe or persistent side effects
- Dehydration
- Worsening of existing gastrointestinal conditions
- Allergic reactions
I understand that GLP-1 medications may not be appropriate for
individuals with certain medical conditions, including a history of medullary
thyroid carcinoma, multiple endocrine neoplasia type 2 (MEN 2), pancreatitis,
or other contraindications, and that full disclosure of my medical history is
required.
Individual Response
and Monitoring
I understand that individual responses to medication vary. I agree to
follow the prescribed dosing instructions, avoid changing doses without medical
guidance, and report side effects promptly. I understand that medication
adjustments, pauses, or discontinuation may be recommended based on my response
or tolerance.
Patient
Responsibilities
I agree to:
- Provide complete and accurate medical information
- Disclose all current medications and medical conditions
- Attend recommended follow-up visits
- Communicate side effects or concerns in a timely manner
- Follow lifestyle, nutrition, and activity recommendations as advised
Emergency Care
I understand that Willow Health, LLC does not provide emergency services.
I agree to seek immediate medical attention or call 911 for severe symptoms,
including but not limited to severe abdominal pain, persistent vomiting, chest
pain, shortness of breath, or signs of an allergic reaction.
Acknowledgment and
Consent
By signing below, I confirm that I have read and understand this informed
consent, have had the opportunity to ask questions, and voluntarily agree to
participate in medical weight loss treatment through Willow Health, LLC.
