WildBerryMD – Informed Consent and Acknowledgment of Risk for Compounded GLP-1 /GIP/ Cyanocobalamin (Weight Loss Injection) Telehealth Treatment

Please read this document carefully. Your signature confirms that you understand and voluntarily agree to the information provided, including the risks, responsibilities, limitations, and terms associated with receiving compounded GLP-1/GIP/Cyanocobalamin therapy via telehealth from WildBerryMD.

What Is Compounded GLP-1/GIP/Cyanocobalamin?

GLP-1 (glucagon-like peptide-1) and GIP (glucose-dependent insulinotropic polypeptide) are incretin hormones that regulate appetite, blood sugar, and digestion. Dual receptor agonists (GLP-1/GIP) mimic these natural hormones, helping slow digestion, stabilize blood sugar levels, reduce appetite, and control cravings. These effects may support healthy, sustained weight loss when combined with lifestyle changes such as proper nutrition and regular physical activity.

At WildBerryMD, Compounded GLP-1/GIP is combined with Cyanocobalamin (Vitamin B12) to support overall metabolic health.

• Cyanocobalamin (Vitamin B12) supports red blood cell formation, nerve function, and energy production. B12 deficiency is common and can contribute to fatigue, brain fog, and slow metabolism. Supplementing B12 may help support mood, energy levels, and metabolic balance during weight loss.

WildBerryMD uses an individualized dose adjustment protocol for compounded GLP-1/GIP/Cyanocobalamin. Your dose may be gradually increased based on your clinical response, side effect profile, and health history, including any pre-existing conditions or medication use. This approach is designed to support safe, effective treatment while minimizing discomfort or adverse effects.

Instructions and Lifestyle Guidelines

• Follow a healthy diet plan with fiber and whole foods.
• Eat slowly and stop eating when full.
• Drink at least 62 oz of water daily to stay hydrated and avoid constipation.
• Avoid overeating, alcohol, fried, greasy, processed, sugary, high-carbohydrate, or spicy foods as they may worsen nausea, heartburn, or bloating.
• Alcohol can lower blood sugar to unsafe levels.
• Engage in 30–60 minutes of moderate exercise daily (e.g., walking).
• Long-term weight management depends on consistent lifestyle changes. Discontinuing GLP-1/GIP may lead to the return of hunger, increased cravings, and potential weight regain.

Contraindications – Do NOT Use If You:

• Are allergic to GLP-1, GIP, cyanocobalamin, or other formulation ingredients.
• Are pregnant, breastfeeding, or planning pregnancy within 2 months.
• Have a personal or family history of medullary thyroid carcinoma (MTC) or multiple endocrine neoplasia type 2 (MEN2).
• Have or have had gastroparesis, pancreatitis, bowel obstruction, gallbladder disease, or severe constipation.
• Have significant kidney disease.
• Have uncontrolled GERD or frequent severe hypoglycemia.
• Have Type 1 diabetes, or Type 2 diabetes and are currently using insulin or certain oral diabetes medications.
• Experience retinopathy, suicidal thoughts, or untreated major psychiatric illness.
• Are scheduled for surgery within 2 weeks.

Possible Risks and Side Effects of Compounded GLP-1/GIP/Cyanocobalamin

This is not an exhaustive list.

• Gastrointestinal Upset: Nausea, vomiting, diarrhea, constipation, indigestion, belching, bloating, heartburn, abdominal discomfort.
• Fatigue, dizziness, headaches (sometimes from low blood sugar).
• Hypoglycemia (low blood sugar), especially if combined with insulin or sulfonylureas.
• Elevated heart rate.
• Allergic reactions (rare but may be severe; call 911 if needed).
• Infection risk at injection site.
• Pancreatitis: Severe abdominal pain ± vomiting.
• Gallbladder issues: Gallstones, jaundice, pale stools, fever.
• Gastroparesis / bowel obstruction.
• Kidney complications from dehydration.
• Thyroid C-cell tumors (risk observed in animal studies; report hoarseness, neck lump, or swallowing difficulty).
• Vision changes: Worsening diabetic retinopathy.
• Rare NAION (optic nerve damage) and sudden vision loss.
• Rare blood clots (DVT/PE).

Medication Interactions

Do not combine with:

• Other GLP-1 receptor agonists (Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy®, Mounjaro®).
• Insulin or sulfonylureas without direct provider guidance.
• Other prescription or OTC appetite suppressants without provider approval.

Monitor blood pressure if taking antihypertensives, as weight loss may lower blood pressure.

No Guarantee of Results

Weight loss outcomes vary. Results are not guaranteed. Discontinuation may result in weight regain. Compounded GLP-1/GIP/Cyanocobalamin is not a permanent fix and requires ongoing lifestyle changes.

Financial Responsibility

• All services are self-pay; insurance is not accepted.
• Payments are due in full at time of service.
• Programs, services, and compounded medications are non-refundable and non-exchangeable.

Alternatives

• No treatment.
• Lifestyle/diet modifications.
• Structured activity programs.
• Other non-surgical weight loss therapies.
• Surgical bariatric procedures.
• FDA-approved branded medications (e.g., Wegovy, Zepbound, Mounjaro).

Self-Administration and Disposal

• Administer once weekly, refrigerate immediately.
• Never reuse needles.
• Dispose of sharps in puncture-resistant sealed containers per Arizona ADEQ guidelines.

Off-Label Use and Disclosures

• Compounded GLP-1/GIP/Cyanocobalamin is not FDA-approved.
• Made by a 503A compounding pharmacy.
• Not interchangeable with Zepbound, Ozempic®, Wegovy®, or Mounjaro®.
• Delivery may take 7–10 business days; delays possible.
• Pharmacy partners may change at WildBerryMD’s discretion.

Voluntary Participation & Telehealth Acknowledgment

• I may pause or stop treatment but risk weight regain.
• I will notify WildBerryMD of any side effects.
• I understand WildBerryMD does not provide primary care or emergency services.
• I agree to maintain a primary care provider.
• In emergencies, I will call 911.

Assumption of Risk & Indemnification

I release and hold harmless WildBerryMD and its representatives from all claims arising from participation in this elective program, except in cases of gross negligence or willful misconduct.

Severability & Entire Agreement

If any clause is invalid, the rest remains in effect. This agreement replaces any prior verbal or written statements.

Patient Acknowledgment & Consent

By signing below, I acknowledge:

• I have read and understood this consent.
• I understand results are not guaranteed.
• I consent to proceed with Compounded GLP-1/GIP/Cyanocobalamin therapy via telehealth with WildBerryMD.
• My electronic signature is legally binding.

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Consent Description

WildBerryMD – Informed Consent and Acknowledgment of Risk for Compounded GLP-1/GIP/Cyanocobalamin (Weight Loss Injection) Telehealth Treatment Please read this document carefully. Your signature confirms that you understand and voluntarily agree to the information provided, including the risks, responsibilities, limitations, and terms associated with receiving compounded GLP-1/GIP/Cyanocobalamin therapy via telehealth from WildBerryMD. What Is Compounded GLP-1/GIP/Cyanocobalamin? GLP-1 (glucagon-like peptide-1) and GIP (glucose-dependent insulinotropic polypeptide) are incretin hormones that regulate appetite, blood sugar, and digestion. Dual receptor agonists (GLP-1/GIP) mimic these natural hormones, helping slow digestion, stabilize blood sugar levels, reduce appetite, and control cravings. These effects may support healthy, sustained weight loss when combined with lifestyle changes such as proper nutrition and regular physical activity. At WildBerryMD, Compounded GLP-1/GIP is combined with Cyanocobalamin (Vitamin B12) to support overall metabolic health. • Cyanocobalamin (Vitamin B12) supports red blood cell formation, nerve function, and energy production. B12 deficiency is common and can contribute to fatigue, brain fog, and slow metabolism. Supplementing B12 may help support mood, energy levels, and metabolic balance during weight loss. WildBerryMD uses an individualized dose adjustment protocol for compounded GLP-1/GIP/Cyanocobalamin. Your dose may be gradually increased based on your clinical response, side effect profile, and health history, including any pre-existing conditions or medication use. This approach is designed to support safe, effective treatment while minimizing discomfort or adverse effects. ________________________________________ Instructions and Lifestyle Guidelines • Follow a healthy diet plan with fiber and whole foods. • Eat slowly and stop eating when full. • Drink at least 62 oz of water daily to stay hydrated and avoid constipation. • Avoid overeating, alcohol, fried, greasy, processed, sugary, high-carbohydrate, or spicy foods as they may worsen nausea, heartburn, or bloating. • Alcohol can lower blood sugar to unsafe levels. • Engage in 30–60 minutes of moderate exercise daily (e.g., walking). • Long-term weight management depends on consistent lifestyle changes. Discontinuing GLP-1/GIP may lead to the return of hunger, increased cravings, and potential weight regain. ________________________________________ Contraindications – Do NOT Use If You: • Are allergic to GLP-1, GIP, cyanocobalamin, or other formulation ingredients. • Are pregnant, breastfeeding, or planning pregnancy within 2 months. • Have a personal or family history of medullary thyroid carcinoma (MTC) or multiple endocrine neoplasia type 2 (MEN2). • Have or have had gastroparesis, pancreatitis, bowel obstruction, gallbladder disease, or severe constipation. • Have significant kidney disease. • Have uncontrolled GERD or frequent severe hypoglycemia. • Have Type 1 diabetes, or Type 2 diabetes and are currently using insulin or certain oral diabetes medications. • Experience retinopathy, suicidal thoughts, or untreated major psychiatric illness. • Are scheduled for surgery within 2 weeks. ________________________________________ Possible Risks and Side Effects of Compounded GLP-1/GIP/Cyanocobalamin This is not an exhaustive list. • Gastrointestinal Upset: Nausea, vomiting, diarrhea, constipation, indigestion, belching, bloating, heartburn, abdominal discomfort. • Fatigue, dizziness, headaches (sometimes from low blood sugar). • Hypoglycemia (low blood sugar), especially if combined with insulin or sulfonylureas. • Elevated heart rate. • Allergic reactions (rare but may be severe; call 911 if needed). • Infection risk at injection site. • Pancreatitis: Severe abdominal pain ± vomiting. • Gallbladder issues: Gallstones, jaundice, pale stools, fever. • Gastroparesis / bowel obstruction. • Kidney complications from dehydration. • Thyroid C-cell tumors (risk observed in animal studies; report hoarseness, neck lump, or swallowing difficulty). • Vision changes: Worsening diabetic retinopathy. • Rare NAION (optic nerve damage) and sudden vision loss. • Rare blood clots (DVT/PE). ________________________________________ Medication Interactions Do not combine with: • Other GLP-1 receptor agonists (Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy®, Mounjaro®). • Insulin or sulfonylureas without direct provider guidance. • Other prescription or OTC appetite suppressants without provider approval. Monitor blood pressure if taking antihypertensives, as weight loss may lower blood pressure. ________________________________________ No Guarantee of Results Weight loss outcomes vary. Results are not guaranteed. Discontinuation may result in weight regain. Compounded GLP-1/GIP/Cyanocobalamin is not a permanent fix and requires ongoing lifestyle changes. ________________________________________ Financial Responsibility • All services are self-pay; insurance is not accepted. • Payments are due in full at time of service. • Programs, services, and compounded medications are non-refundable and non-exchangeable. ________________________________________ Alternatives • No treatment. • Lifestyle/diet modifications. • Structured activity programs. • Other non-surgical weight loss therapies. • Surgical bariatric procedures. • FDA-approved branded medications (e.g., Wegovy, Zepbound, Mounjaro). _______________________________________ Self-Administration and Disposal • Administer once weekly, refrigerate immediately. • Never reuse needles. • Dispose of sharps in puncture-resistant sealed containers per Arizona ADEQ guidelines. _______________________________________ Off-Label Use and Disclosures • Compounded GLP-1/GIP/Cyanocobalamin is not FDA-approved. • Made by a 503A compounding pharmacy. • Not interchangeable with Zepbound, Ozempic®, Wegovy®, or Mounjaro®. • Delivery may take 7–10 business days; delays possible. • Pharmacy partners may change at WildBerryMD’s discretion. _______________________________________ Voluntary Participation & Telehealth Acknowledgment • I may pause or stop treatment but risk weight regain. • I will notify WildBerryMD of any side effects. • I understand WildBerryMD does not provide primary care or emergency services. • I agree to maintain a primary care provider. • In emergencies, I will call 911. _______________________________________ Assumption of Risk & Indemnification I release and hold harmless WildBerryMD and its representatives from all claims arising from participation in this elective program, except in cases of gross negligence or willful misconduct. _______________________________________ Severability & Entire Agreement If any clause is invalid, the rest remains in effect. This agreement replaces any prior verbal or written statements _______________________________________ Patient Acknowledgment & Consent By signing below, I acknowledge: • I have read and understood this consent. • I understand results are not guaranteed. • I consent to proceed with Compounded GLP-1/GIP/Cyanocobalamin therapy via telehealth with WildBerryMD. • My electronic signature is legally binding.

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