Compounded Medication Informed Consent

A compounded medication is prepared by a state-licensed pharmacy for an individual patient, based on a valid prescription from a licensed provider.

Compounded semaglutide and compounded tirzepatide are not FDA-approved. They have not been reviewed by the FDA for safety, effectiveness or quality.

Compounded medications are not the same as brand-name products. They may contain different inactive ingredients — for example, added vitamins.

Your dose is measured in units or mL on your syringe. Always follow the label on your medication and your provider's instructions. If anything is unclear, ask us before you take your dose.

• Nausea
• Constipation
• Diarrhea
• Reduced appetite
• Mild redness where you give the shot

Tell us if side effects bother you, so your provider can review your dose.

• Pancreatitis (inflammation of the pancreas).
• Gallbladder problems.
• Low blood sugar, especially if you also take diabetes medicines.
• Kidney problems from dehydration.
• Allergic reactions.
• A possible risk of thyroid C-cell tumors, seen in animal studies. Do not use this medication if you or a family member has had medullary thyroid cancer, or if you have MEN2 (Multiple Endocrine Neoplasia syndrome type 2).

For emergencies, call 911.

• Not for use during pregnancy or breastfeeding.
• If you become pregnant, stop the medication and tell your provider.
• Use effective birth control while taking this medication.

• Tell your provider about all medications and supplements you take.
• Tell your provider before any surgery or anesthesia.

• Keep it in the refrigerator.
• Do not freeze it.
• Protect it from light.
• Throw it away after the beyond-use date on the label.

• Never share needles or syringes with anyone.
• Dispose of used needles safely in a sharps container.

Results vary from person to person and are not guaranteed.

You may stop treatment at any time. Please tell your provider if you do.

By continuing with sign-up, you confirm you have read and understood this consent, had the chance to ask questions, and agree to receive compounded medication if your provider prescribes it.