WildBerryMD – Informed Consent and Acceptance of Risk for Compounded Semaglutide Telehealth Treatment
PLEASE READ CAREFULLY: By signing this document, you confirm that you understand and voluntarily agree to the information provided below, including the risks, responsibilities, limitations, and terms associated with receiving compounded semaglutide therapy via telehealth from WildBerryMD.
1. What Is Compounded Semaglutide?
Semaglutide is a glucagon-like peptide-1 (Weight Loss Capsules) receptor agonist that mimics a natural hormone in the body. It helps slow digestion, stabilize blood sugar levels, reduce appetite, and control cravings. These effects may support sustainable weight loss when combined with nutrition, exercise, and behavioral changes. WildBerryMD offers semaglutide compounded with either L-Carnitine, to support fat metabolism and energy, or Cyanocobalamin (Vitamin B12), which can enhance mood, focus, and metabolism. You have chosen to use Semaglutide capsules.
2. Instructions and Lifestyle Guidelines
I understand that to reduce side effects and improve outcomes, I should follow a high-fiber, whole-food diet, eat slowly, and stop eating when full. I will drink at least 62 ounces of water daily to avoid dehydration. I will avoid alcohol, greasy or sugary foods, and lying down after meals. I will engage in moderate physical activity for at least 30 minutes daily. I understand that discontinuing semaglutide may cause hunger, cravings, or weight regain, and that long-term lifestyle changes are essential for lasting results.
3. Contraindications: Do not use compounded semaglutide if any of the following apply to you:
- Allergy to semaglutide
- Pregnancy, breastfeeding, or planning to become pregnant
- History of medullary thyroid carcinoma (MTC) -(You or an immediate family member)
- Have an endocrine system condition called Multiple Endocrine Neoplasia syndrome type 2
- Gastroparesis, bowel obstruction, Crohn’s disease, or ulcerative colitis
- Pancreatitis, gallbladder disease, or recent gallbladder removal
- Kidney disease, chronic impairment, kidney stones, or risk of dehydration
- Uncontrolled GERD or active liver disease
- Low blood sugar (hypoglycemia)
- Type 1 diabetes or use of insulin/sulfonylureas for Type 2 diabetes
- Diabetic Retinopathy
- Active eating disorder
- Untreated major depression, suicidal ideation, or suicide attempt history
- Scheduled for surgery within 2 weeks
- BMI under 27
4. Common Side Effects:
Serious or Less Common Side Effects:
- Hypoglycemia: Low blood sugar symptoms may include shakiness, sweating, confusion, rapid heart rate, or fainting — especially when combined with insulin or certain diabetes medications.
- Pancreatitis: Severe abdominal pain radiating to the back, nausea, or vomiting may signal inflammation of the pancreas. Seek immediate medical care.
- Kidney Problems: Dehydration from vomiting or diarrhea may reduce kidney function or contribute to kidney stones (symptoms include back pain, blood in urine, or painful urination).
- Blood Clots: Including deep vein thrombosis (DVT) or pulmonary embolism.
- Gallbladder Issues: Pain, yellowing of skin/eyes, pale stools, and fever may signal gallstones or infection; removal may be necessary.
- Gastroparesis or Gastrointestinal Blockage: Severe slowing or stopping of stomach or intestinal movement, including conditions such as gastroparesis (delayed stomach emptying), bowel obstruction (blockage in the intestines), or ileus (paralysis of intestinal movement), which can prevent normal digestion and passage of food.
- Hair Loss: Telogen effluvium (hair shedding) may occur due to rapid weight loss or nutritional changes. Not a common or confirmed side effect, but discuss any significant hair loss with your provider.
- Mood Changes: Rare reports of depression or suicidal thoughts have been observed. If you have a history of mood disorders, monitor symptoms closely. Notify WildBerryMD if you experience hopelessness or suicidal ideation.
Emergency Situations and Special Warnings:
- Hives, swelling, or throat tightness — call 911 immediately.
- Thyroid Tumors and cancer: Animal studies show risk of thyroid C-cell tumors and thyroid cancer. If thyroid cancer happens, it may be deadly if not found or treated early. Call your Doctor right away if you have a neck mass, trouble breathing, trouble swallowing or have hoarseness that will not go away.
- Vision Changes: Temporary vision worsening may occur in patients with diabetic retinopathy. Rare cases of sudden vision loss (NAION) have been reported and remain under investigation.
- Other Known or Unknown Risks: As with any medical treatment, other side effects may occur that are not listed or not yet known. Promptly report any unusual symptoms
5. Drug Interactions:
I understand that I will not use semaglutide with other Weight Loss Capsules agonists (e.g., Ozempic®, Wegovy®, Mounjaro®, Victoza),insulin, sulfonylureas(e.g. Glipizide, Glyburide, or any other type 2 diabetic meds) or over-the-counter appetite suppressants. It may slow digestion, alter medication absorption or result in serious side effects. Monitor blood pressure if also on antihypertensives. I agree that I am responsible for disclosing all current medications, prescriptions, vitamins, herbal and dietary supplements and accurate health history to WildBerryMD. I understand that failure to do so may result in serious or adverse side effects.
6. No Guarantee of Results
I understand Compounded semaglutide is not a cure for obesity or a guaranteed solution. Weight loss and health outcomes vary widely between individuals. Some patients may require ongoing or long-term use to maintain results. Discontinuation may result in return of appetite, cravings, and weight regain. WildBerryMD makes no express or implied promises regarding weight loss, improved health, or duration of results. Long-term lifestyle changes—including healthy nutrition, exercise, and behavior modification are key to maintaining weight loss and supporting lasting results.
7. Financial Responsibility
I understand that all services provided by WildBerryMD are elective and self-pay. I agree to pay all charges in full at the time of service, including telehealth consultations, compounded medications, and related care. All payments are non-refundable and non-transferable, regardless of outcome or satisfaction. I will not initiate credit card chargebacks or seek reimbursement from my financial institution for services rendered. If I do so, I acknowledge that I will be responsible for any related fees, collection costs, or legal expenses incurred by WildBerryMD in resolving the dispute.
8.Alternatives to Treatment
I understand that alternatives include lifestyle changes, behavioral support, non-Weight Loss Capsules medications, or surgery. I may decline treatment at any time.
9. Off-Label Use and FDA Disclosure
Compounded semaglutide is prescribed off-label for weight loss and is not FDA-approved for this purpose. Ozempic® and Wegovy® are FDA-approved brands. Compounded medications are prepared by licensed 503A compounding pharmacies in accordance with applicable state and federal regulations; however, they have not been reviewed, evaluated, or approved by the U.S. Food and Drug Administration (FDA) for safety, effectiveness, or quality. They are not interchangeable with brand products. Pharmacy partners may change. Delivery takes 7–10 business days but is not guaranteed.
10. Telehealth Disclosure
I understand that WildBerryMD provides virtual, elective wellness services via Telehealth only and is not a substitute for my primary care physician or any specialist involved in my medical care. I acknowledge that WildBerryMD does not provide emergency care, primary care, or management of urgent or chronic medical conditions. I agree to maintain an ongoing relationship with my primary care provider and any appropriate specialists for routine health screenings, preventative care, management of medical conditions, lab testing, medication reviews, and any other necessary medical services. In the event of a medical emergency, I agree to call 911 or go to the nearest emergency room immediately. I understand that it is my responsibility to inform my primary care provider, specialists, surgeons, or other healthcare providers of any treatments or services I receive from WildBerryMD, especially when relevant to my overall care or before undergoing any medical procedures.
11. Risk Acknowledgment and Indemnification
By choosing to participate in this elective compounded semaglutide program through telehealth, I voluntarily accept and assume all risks associated with treatment. This includes, but is not limited to, potential side effects, complications, delays in medication delivery, and the possibility that treatment outcomes may vary or be unsatisfactory.
I agree to release, defend, indemnify, and hold harmless WildBerryMD, its owners, providers, employees, contractors, agents, affiliated pharmacy partners, and all related entities (“WildBerryMD and its Representatives”) from any and all claims, demands, damages, losses, or legal actions (including reasonable attorney’s fees and costs) arising from or related to:
- My decision to receive compounded semaglutide treatment;
- Any failure on my part to disclose accurate medical history or medication use;
- My noncompliance with medical instructions or recommended lifestyle changes;
- Pharmacy delays, changes in pharmacy partners, or shipment issues beyond WildBerryMD’s control;
- Any side effects, illnesses, complications, or unexpected outcomes, except in cases of gross negligence or intentional misconduct as defined by Arizona law.
This release and indemnification shall be applied to the fullest extent allowed by law and does not waive any rights that cannot be legally waived under applicable state or federal law.
12. Agreement and Severability
I understand that this document represents the full and complete agreement between myself and WildBerryMD regarding the services described. If any part of this agreement is determined to be invalid or unenforceable, the remaining provisions will continue in full force and effect.
13. Patient Acknowledgment and Consent
By signing below, I confirm that:
- I am at least 18 years of age and a resident of Arizona.
- I have carefully read, fully understand, and voluntarily agree to all terms, risks, responsibilities, and disclosures outlined in this informed consent form.
- I have been given the opportunity to ask questions and have received clear, satisfactory answers.
- I am electing to receive compounded semaglutide treatment via telehealth from WildBerryMD
- I understand and agree to the inherent risks, benefits, and limitations described in the WildBerryMD Telehealth Agreement, including the limitations of not having an in-person physical examination and the nature of receiving services via telemedicine.
- I understand that this treatment is elective, is not guaranteed to be effective, and that individual results may vary.
- I understand and agree that my signature applies to all sections of this consent form, and no additional initials are required.
- I am providing this consent freely, without pressure or obligation, as part of my informed choice.
- I understand this is a legally binding agreement, and that my electronic signature carries the same legal effect as a handwritten signature.
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