Weight Loss Injections Consent

WildBerryMD – Informed Consent and Acknowledgment of Risk for Compounded Semaglutide (Weight Loss Injections) 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 semaglutide therapy via telehealth from WildBerryMD.

What Is Compounded Semaglutide?

Semaglutide is a glucagon-like peptide-1 (Weight Loss Injections) receptor agonist that mimics a natural hormone in the body. It works by slowing digestion, stabilizing blood sugar levels, reducing appetite, and helping to 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, Semaglutide is offered in a compounded formulation, combined with either L-Carnitine or Cyanocobalamin (Vitamin B12) to support overall metabolic health. L-Carnitine may assist with fat metabolism and cellular energy production. It helps transport fatty acids into mitochondria, where they are used for energy, which may improve endurance, fat utilization, and exercise recovery. 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 semaglutide. 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

It is recommended to follow a healthy diet plan with fiber and whole foods, eat slowly, and stop eating when you feel full. Drink plenty of water (62 oz a day) to keep hydrated and avoid constipation. Overeating or consuming large meals, alcohol, fried, greasy, processed, sugary, high-carbohydrate, or spicy foods may increase the risk of nausea, gerd, heart burn, vomiting, bloating, or abdominal discomfort. Avoid alcohol as it can lower your blood sugars to unhealthy levels. Engage in daily moderate exercise, such as 30–60 minutes of walking. Lifestyle change—including healthy diet, exercise, and behavior modification—is critical to achieving and sustaining long-term results. You understand that discontinuing Semaglutide may lead to the return of hunger, increased cravings, and potential weight regain. Medical conditions associated with obesity may also reoccur. Therefore, it is important to maintain long-term lifestyle changes, including healthy nutrition and regular physical activity to support ongoing weight management

You should not use this medication for weight loss if you:

Are allergic to semaglutide, L-carnitine, cyanocobalamin (Vitamin B12), or any of the ingredients in the compounded formulation. Do not use if you have a history of severe allergic reactions (anaphylaxis) to medications or injectable therapies.
Are currently pregnant, breastfeeding, or planning to become pregnant within the next 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 the next 2 weeks

Possible Risks and Side Effects with Compounded Semaglutide Weight Management Treatment:

This list is not exhaustive of all possible risks associated with Compounded Semaglutide weight management treatment.

Gastrointestinal Upset: Common treatment side effects include nausea, vomiting, diarrhea, constipation, indigestion, belching, bloating, heart burn, and abdominal discomfort. Gradual dosing adjustments might mitigate these effects, or further adjustments may be necessary if side effects persist. Your healthcare provider can recommend strategies or medications to alleviate these symptoms, such as consuming meals slowly, opting for bland foods, avoiding fatty foods, and refraining from lying down immediately after eating.
Fatigue, Dizziness, and Headaches: Some individuals may encounter fatigue, dizziness, or headaches, potentially linked to low blood sugar levels. If these symptoms manifest, it’s advisable to discuss them with your treatment provider.
Hypoglycemia: An increased risk of low blood sugar (hypoglycemia) exists, particularly in patients with type 2 diabetes taking insulin or sulfonylureas. Symptoms may include dizziness, headache, rapid heartbeat, mood fluctuations, weakness, shakiness, confusion, or hunger. Your healthcare provider can guide you on recognizing and managing low blood sugar. If you have type 2 diabetes, monitor your blood sugar levels as instructed.
Elevated Heart Rate: Resting heart rate elevation may occur. If you notice a rapid or pounding heartbeat persisting for several minutes or longer, promptly inform your healthcare provider.
Allergic Reactions or Hypersensitivity: Although rare, allergic reactions or severe hypersensitivity reactions can occur, marked by symptoms like hives, breathing difficulties, facial swelling, or throat tightness. Additional treatment may be necessary in case of an allergic reaction. Call 911 in case of a rare allergic reaction.
Infection: Infection risk at the injection site, while uncommon, may necessitate additional interventions like antibiotics or procedures.
Pancreatitis: Inflammation of the pancreas (pancreatitis) is a potential complication. Notify your provider promptly if you experience severe stomach pain with or without vomiting.
Gallbladder Complications: Gallbladder-related concerns, including gallstones, might manifest as upper stomach pain, yellowing of skin/eyes, pale stools, or fever. Alert your provider immediately if you encounter these symptoms.
Gastroparesis, Gastrointestinal Issues and Severe Constipation: Rarely, Gastroparesis and/or gastrointestinal blockage (ileus) might occur, leading to persistent constipation, abdominal distension, appetite loss, inability to pass gas, or vomiting. An ileus necessitates timely intervention to prevent severe consequences.
Dehydration and Kidney Complications: Potential risks include dehydration leading to acute kidney injury or worsened renal function due to gastrointestinal reactions. Adequate fluid intake is essential to reduce dehydration-related kidney risks.
Thyroid C-cell Tumors: When using semaglutide, there is a potential risk of thyroid C-cell tumors. It is crucial to alert your healthcare provider if you experience any indications of thyroid tumors, such as persistent hoarseness, breathing difficulties, a neck mass, or swallowing challenges.
Vision Alterations: Individuals with diabetic retinopathy may observe changes in vision while undergoing semaglutide treatment. This could be linked to a swift enhancement in glucose management, potentially resulting in temporary exacerbation of retinopathy. Long-term effects of glycemic control on diabetic retinopathy remain unstudied. Please inform your healthcare provider promptly about any vision changes.
Rare cases of sudden vision loss, including non-arteritic anterior ischemic optic neuropathy (NAION), have been reported and are under investigation
Rare cases of blood clots (such as deep vein thrombosis or pulmonary embolism) have been reported. Risk may be increased in patients with certain underlying conditions. Seek emergency care for symptoms such as leg swelling, chest pain, or shortness of breath.

Potential Serious Interactions and Decreased Effectiveness of Medications: Including Prescription, Over-the-Counter Drugs, Herbal Supplements, and Minerals: (THIS IS NOT AN ALL-INCLUSIVE LIST).

Do not take with other Weight Loss Injections agonist medicines such as: Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy® Mounjaro® .Do not take with Anti-diabetic agents, specifically insulin and sulfonylureas (e.g., glyburide, glipizide, glimepiride, tolbutamide) due to the increased risk of hypoglycemia (low blood sugar). Do not take with other prescription or non-prescription appetite suppressants without discussing with the provider as serious side effects can happen

If you are on Blood pressure medications: As weight loss may occur on this medication, it is imperative to monitor your blood pressure at home while on this medication and taking blood pressure medication at the same time. Weight loss may naturally decrease your blood pressure, which may make it necessary to adjust your blood pressure medication dosage. As weight loss occurs, it is recommended to keep a blood pressure diary.

Specific herbal products, medications, and supplements can influence the functionality of semaglutide, potentially leading to reduced treatment efficacy or increased side effects. Semaglutide’s impact on gastric emptying may alter the absorption of oral medications, possibly affecting their effectiveness or interactions with other drugs.

No Guarantee of Results:

Weight loss results and other health outcomes vary. There is no guarantee of specific weight loss or other health outcomes. Discontinuation may result in weight regain. There is also a likelihood that compounded Semaglutide injections with added vitamins may not yield the desired weight reduction. If complications arise, supplementary treatments may be essential. It is crucial to recognize that semaglutide injections do not offer a permanent fix for weight management and necessitate ongoing lifestyle adjustments and dietary changes; periodic maintenance semaglutide injections might be necessary to sustain the desired weight. In some cases patients may require long-term use of compounded semaglutide injections to maintain weight. The duration and certainty of weight loss results remain uncertain and are not guaranteed.

Financial Responsibility

I understand that I am fully responsible for the cost of services and medications provided. Insurance is not accepted. Payments are due in full at time of service and all programs, services and compounded medications are non-refundable and non-exchangeable. Should I find the outcomes unsatisfactory, I agree not to pursue reimbursement for the services received for compounded semaglutide treatment, recognizing the absence of any implicit or explicit result guarantee, as detailed in the preceding acknowledgment. I agree that in the event of non-payment or a credit card chargeback initiated by me, I will be accountable for any collection fees, potential court fees, and reasonable legal expenses incurred due to such circumstances.

Alternative Treatment Options for weight loss

I understand that alternative options to compounded Semaglutide therapy exist and may include: No treatment at all; Dietary modification and lifestyle interventions; Structured physical activity programs; Other non-surgical medical weight loss therapies; Surgical weight loss procedures (e.g., bariatric surgery); brand name FDA approved medications for weight loss like Wegovy or Zepbound, or Ozempic for off-label use for weight loss
I acknowledge that all medical treatments carry potential risks and benefits. The decision to proceed with compounded Semaglutide therapy should be based on an individual assessment of these risks in comparison to the anticipated benefits. While serious complications are uncommon, they may occur. I have been advised to discuss any concerns or questions regarding treatment risks, alternatives, or expectations with my healthcare provider.
I confirm that the available treatment alternatives, including the option to decline therapy, have been discussed with me and that I have had the opportunity to make an informed decision regarding my care.

Self-Administration of Semaglutide Injections

I understand that compounded semaglutide injections are administered once every seven days and must be refrigerated immediately upon receipt.
I have been trained in the proper self-injection technique and confirm that I feel comfortable performing injections independently.
I understand the importance of storing semaglutide correctly and handling and disposing of all injection-related materials safely.
I understand that needles must never be reused due to the risk of infection or injury.
I acknowledge that drawing the correct dose is essential for safety and effectiveness, and that overdosing may lead to serious side effects.
I will sanitize the injection site with an alcohol pad prior to injection to help prevent infection.
I am aware that injection-related side effects may include bruising, redness, irritation, or discomfort at the injection site.
I acknowledge that WildBerryMD is not responsible for injuries, complications, or adverse outcomes resulting from improper injection technique, incorrect storage, or misuse of compounded semaglutide.

Safe Disposal of Sharps (Arizona Guidelines)

In Arizona, home-generated sharps may be disposed of in the regular household trash if the following safety procedures are followed:

Place all used needles, syringes, and sharps in a puncture-resistant, sealable container (e.g., an FDA-cleared sharps container or a heavy-duty plastic container such as a laundry detergent bottle).
Seal the container lid securely and reinforce it with strong tape.
Clearly label the container with “Not Recyclable” or “Sharps” as recommended by ADEQ guidelines.
Do not place sharps in recycling. Dispose of the sealed, labeled container in the regular household trash.
Never dispose of loose needles or syringes directly into household garbage.

For additional information, please refer to: Safe Needle Disposal – Arizona Guidelines(https://safeneedledisposal.org/states/arizona/)

Compounded Semaglutide – Off-Label Use and Disclosures

By signing below, I acknowledge and agree to the following:

I understand that compounded semaglutide is not approved by the U.S. Food and Drug Administration (FDA) for safety, efficacy, or manufacturing quality. It is being prescribed for off-label use in weight management and has not been formally evaluated or approved by the FDA for this indication.

The compounded medication is prepared by a 503A state-licensed compounding pharmacy operating under applicable state and federal regulations. Compounded semaglutide is not interchangeable with FDA-approved brands such as Ozempic® or Wegovy®, and individual results and tolerability may vary.

I understand that post-marketing studies and safety monitoring are ongoing, and that long-term safety, effectiveness, and outcomes of compounded semaglutide have not been fully established. There may be known and unknown risks and side effects associated with its use.

WildBerryMD reserves the right to change pharmacy partners at any time, without prior notice, based on availability, pricing, compliance standards, shipping delays, or other clinical or business needs.

Once prescribed, delivery may take approximately 7 to 10 business days. While WildBerryMD and its pharmacy partners strive to ensure timely delivery, I acknowledge that shipping delays may occur due to factors beyond their control, including supply shortages, pharmacy processing times, or carrier delays. Delivery timelines are not guaranteed.

2. Voluntary Participation and Telehealth Acknowledgment

By choosing to receive semaglutide therapy through WildBerryMD’s telehealth platform, I understand and agree to the following:

I may pause, discontinue, or adjust treatment at any time. However, I understand that abruptly stopping semaglutide may result in a return of hunger, cravings, or weight regain. I agree to consult with WildBerryMD before making any changes to my treatment plan.
I agree to notify WildBerryMD immediately if I experience side effects or feel unwell, and I will stop using the medication until further medical guidance is provided.
I understand that WildBerryMD is a wellness-focused telemedicine provider and does not provide emergency medical care or primary care services. I agree to maintain care with my primary care provider and appropriate specialists for routine, preventative, urgent, or chronic medical needs, including lab work and medication clearance as needed.
In the event of a medical emergency, I will call 911 or go to the nearest emergency facility. I will not rely on WildBerryMD for urgent care.
I am responsible for:
- Providing accurate and complete health information, including any changes in medications, diagnoses, weight, blood pressure, or lab results.
- Informing my other healthcare providers (e.g., PCP, surgeons, specialists) about my participation in this program and any medications or therapies I am receiving through WildBerryMD.
- Complying with the treatment plan and lifestyle changes recommended for optimal outcomes.

3. Assumption of Risk and Indemnification

In consideration of receiving elective compounded semaglutide therapy via telehealth from WildBerryMD:

I voluntarily assume all risks associated with this treatment, including any adverse reactions, complications, or outcomes, whether known or unknown.
I agree to release, defend, indemnify, and hold harmless WildBerryMD, its providers, staff, contractors, affiliates, and partner pharmacies (collectively, “WildBerryMD and its Representatives”) from any and all claims, demands, damages, costs, or liabilities arising out of:
- My participation in this compounded semaglutide weight management program, including medications, dietary recommendations, or health coaching;
- My failure to fully disclose relevant medical history;
- Shipment delays or changes in pharmacy partners;
- My decision to undergo elective treatment via telehealth.
This indemnification does not apply to gross negligence or willful misconduct and shall be subject to limitations under applicable Arizona law.

4. Severability and Entire Agreement

If any provision of this agreement is determined to be invalid or unenforceable under applicable law, the remainder shall remain in full force and effect. This document represents the entire agreement between me and WildBerryMD regarding compounded semaglutide therapy and supersedes any prior verbal or written statements or agreements.

5. Patient Acknowledgment and Consent

By signing below:

I confirm that I have read, understood, and voluntarily agreed to all of the above terms, risks, and responsibilities related to compounded semaglutide treatment via telehealth.
I acknowledge that I have read, understood, and agree to the inherent risks, limitations, and terms described in the WildBerryMD Telehealth Informed Consent, which governs the delivery of all telemedicine services provided by WildBerryMD.
I understand this consent applies specifically to telehealth services provided by WildBerryMD.
I acknowledge that I have had the opportunity to ask questions and receive answers to my satisfaction.
I consent to initiate and continue compounded semaglutide therapy through WildBerryMD as an elective, self-pay wellness service.
I understand that results are not guaranteed and may vary depending on adherence, health status, and response to treatment.
I agree that my electronic signature is the legal equivalent of my handwritten signature.

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Consent Description

WildBerryMD – Informed Consent and Acknowledgment of Risk for Compounded Semaglutide (Weight Loss Injections) 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 semaglutide therapy via telehealth from WildBerryMD.
What Is Compounded Semaglutide?
Semaglutide is a glucagon-like peptide-1 (Weight Loss Injections) receptor agonist that mimics a natural hormone in the body. It works by slowing digestion, stabilizing blood sugar levels, reducing appetite, and helping to 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, Semaglutide is offered in a compounded formulation, combined with either L-Carnitine or Cyanocobalamin (Vitamin B12) to support overall metabolic health. L-Carnitine may assist with fat metabolism and cellular energy production. It helps transport fatty acids into mitochondria, where they are used for energy, which may improve endurance, fat utilization, and exercise recovery. 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 semaglutide. 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
It is recommended to follow a healthy diet plan with fiber and whole foods, eat slowly, and stop eating when you feel full. Drink plenty of water (62 oz a day) to keep hydrated and avoid constipation. Overeating or consuming large meals, alcohol, fried, greasy, processed, sugary, high-carbohydrate, or spicy foods may increase the risk of nausea, gerd, heart burn, vomiting, bloating, or abdominal discomfort. Avoid alcohol as it can lower your blood sugars to unhealthy levels. Engage in daily moderate exercise, such as 30–60 minutes of walking. Lifestyle change—including healthy diet, exercise, and behavior modification—is critical to achieving and sustaining long-term results. You understand that discontinuing Semaglutide may lead to the return of hunger, increased cravings, and potential weight regain. Medical conditions associated with obesity may also reoccur. Therefore, it is important to maintain long-term lifestyle changes, including healthy nutrition and regular physical activity to support ongoing weight management
You should not use this medication for weight loss if you:
•	Are allergic to semaglutide, L-carnitine, cyanocobalamin (Vitamin B12), or any of the ingredients in the compounded formulation. Do not use if you have a history of severe allergic reactions (anaphylaxis) to medications or injectable therapies.
•	Are currently pregnant, breastfeeding, or planning to become pregnant within the next 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 the next 2 weeks
Possible Risks and Side Effects with Compounded Semaglutide Weight Management Treatment: This list is not exhaustive of all possible risks associated with Compounded Semaglutide weight management treatment. 
•	Gastrointestinal Upset: Common treatment side effects include nausea, vomiting, diarrhea, constipation, indigestion, belching, bloating, heart burn, and abdominal discomfort. Gradual dosing adjustments might mitigate these effects, or further adjustments may be necessary if side effects persist. Your healthcare provider can recommend strategies or medications to alleviate these symptoms, such as consuming meals slowly, opting for bland foods, avoiding fatty foods, and refraining from lying down immediately after eating.
•	Fatigue, Dizziness, and Headaches: Some individuals may encounter fatigue, dizziness, or headaches, potentially linked to low blood sugar levels. If these symptoms manifest, it’s advisable to discuss them with your treatment provider.
•	Hypoglycemia: An increased risk of low blood sugar (hypoglycemia) exists, particularly in patients with type 2 diabetes taking insulin or sulfonylureas. Symptoms may include dizziness, headache, rapid heartbeat, mood fluctuations, weakness, shakiness, confusion, or hunger. Your healthcare provider can guide you on recognizing and managing low blood sugar. If you have type 2 diabetes, monitor your blood sugar levels as instructed.
•	Elevated Heart Rate: Resting heart rate elevation may occur. If you notice a rapid or pounding heartbeat persisting for several minutes or longer, promptly inform your healthcare provider.
•	Allergic Reactions or Hypersensitivity: Although rare, allergic reactions or severe hypersensitivity reactions can occur, marked by symptoms like hives, breathing difficulties, facial swelling, or throat tightness. Additional treatment may be necessary in case of an allergic reaction. Call 911 in case of a rare allergic reaction. 
•	Infection: Infection risk at the injection site, while uncommon, may necessitate additional interventions like antibiotics or procedures.
•	Pancreatitis: Inflammation of the pancreas (pancreatitis) is a potential complication. Notify your provider promptly if you experience severe stomach pain with or without vomiting.
•	Gallbladder Complications: Gallbladder-related concerns, including gallstones, might manifest as upper stomach pain, yellowing of skin/eyes, pale stools, or fever. Alert your provider immediately if you encounter these symptoms.
•	Gastroparesis, Gastrointestinal Issues and Severe Constipation: Rarely, Gastroparesis and/or gastrointestinal blockage (ileus) might occur, leading to persistent constipation, abdominal distension, appetite loss, inability to pass gas, or vomiting. An ileus necessitates timely intervention to prevent severe consequences.
•	Dehydration and Kidney Complications: Potential risks include dehydration leading to acute kidney injury or worsened renal function due to gastrointestinal reactions. Adequate fluid intake is essential to reduce dehydration-related kidney risks.
•	Thyroid C-cell Tumors: When using semaglutide, there is a potential risk of thyroid C-cell tumors. It is crucial to alert your healthcare provider if you experience any indications of thyroid tumors, such as persistent hoarseness, breathing difficulties, a neck mass, or swallowing challenges.
•	Vision Alterations: Individuals with diabetic retinopathy may observe changes in vision while undergoing semaglutide treatment. This could be linked to a swift enhancement in glucose management, potentially resulting in temporary exacerbation of retinopathy. Long-term effects of glycemic control on diabetic retinopathy remain unstudied. Please inform your healthcare provider promptly about any vision changes.
•	Rare cases of sudden vision loss, including non-arteritic anterior ischemic optic neuropathy (NAION), have been reported and are under investigation
•	Rare cases of blood clots (such as deep vein thrombosis or pulmonary embolism) have been reported. Risk may be increased in patients with certain underlying conditions. Seek emergency care for symptoms such as leg swelling, chest pain, or shortness of breath.
Potential Serious Interactions and Decreased Effectiveness of Medications: Including Prescription, Over-the-Counter Drugs, Herbal Supplements, and Minerals: (THIS IS NOT AN ALL-INCLUSIVE LIST).
Do not take with other Weight Loss Injections agonist medicines such as: Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy® Mounjaro® .Do not take with Anti-diabetic agents, specifically insulin and sulfonylureas (e.g., glyburide, glipizide, glimepiride, tolbutamide) due to the increased risk of hypoglycemia (low blood sugar). Do not take with other prescription or non-prescription appetite suppressants without discussing with the provider as serious side effects can happen
If you are on Blood pressure medications: As weight loss may occur on this medication, it is imperative to monitor your blood pressure at home while on this medication and taking blood pressure medication at the same time. Weight loss may naturally decrease your blood pressure, which may make it necessary to adjust your blood pressure medication dosage. As weight loss occurs, it is recommended to keep a blood pressure diary.
Specific herbal products, medications, and supplements can influence the functionality of semaglutide, potentially leading to reduced treatment efficacy or increased side effects. Semaglutide’s impact on gastric emptying may alter the absorption of oral medications, possibly affecting their effectiveness or interactions with other drugs.
No Guarantee of Results:
Weight loss results and other health outcomes vary. There is no guarantee of specific weight loss or other health outcomes. Discontinuation may result in weight regain. There is also a likelihood that compounded Semaglutide injections with added vitamins may not yield the desired weight reduction. If complications arise, supplementary treatments may be essential. It is crucial to recognize that semaglutide injections do not offer a permanent fix for weight management and necessitate ongoing lifestyle adjustments and dietary changes; periodic maintenance semaglutide injections might be necessary to sustain the desired weight. In some cases patients may require long-term use of compounded semaglutide injections to maintain weight. The duration and certainty of weight loss results remain uncertain and are not guaranteed.
Financial Responsibility
I understand that I am fully responsible for the cost of services and medications provided. Insurance is not accepted. Payments are due in full at time of service and all programs, services and compounded medications are non-refundable and non-exchangeable. Should I find the outcomes unsatisfactory, I agree not to pursue reimbursement for the services received for compounded semaglutide treatment, recognizing the absence of any implicit or explicit result guarantee, as detailed in the preceding acknowledgment. I agree that in the event of non-payment or a credit card chargeback initiated by me, I will be accountable for any collection fees, potential court fees, and reasonable legal expenses incurred due to such circumstances.
Alternative Treatment Options for weight loss
•	I understand that alternative options to compounded Semaglutide therapy exist and may include: No treatment at all; Dietary modification and lifestyle interventions; Structured physical activity programs; Other non-surgical medical weight loss therapies; Surgical weight loss procedures (e.g., bariatric surgery); brand name FDA approved medications for weight loss like Wegovy or Zepbound, or Ozempic for off-label use for weight loss 
•	I acknowledge that all medical treatments carry potential risks and benefits. The decision to proceed with compounded Semaglutide therapy should be based on an individual assessment of these risks in comparison to the anticipated benefits. While serious complications are uncommon, they may occur. I have been advised to discuss any concerns or questions regarding treatment risks, alternatives, or expectations with my healthcare provider.
•	I confirm that the available treatment alternatives, including the option to decline therapy, have been discussed with me and that I have had the opportunity to make an informed decision regarding my care.
Self-Administration of Semaglutide Injections
•	I understand that compounded semaglutide injections are administered once every seven days and must be refrigerated immediately upon receipt.
•	I have been trained in the proper self-injection technique and confirm that I feel comfortable performing injections independently.
•	I understand the importance of storing semaglutide correctly and handling and disposing of all injection-related materials safely.
•	I understand that needles must never be reused due to the risk of infection or injury.
•	I acknowledge that drawing the correct dose is essential for safety and effectiveness, and that overdosing may lead to serious side effects.
•	I will sanitize the injection site with an alcohol pad prior to injection to help prevent infection.
•	I am aware that injection-related side effects may include bruising, redness, irritation, or discomfort at the injection site.
•	I acknowledge that WildBerryMD is not responsible for injuries, complications, or adverse outcomes resulting from improper injection technique, incorrect storage, or misuse of compounded semaglutide.
Safe Disposal of Sharps (Arizona Guidelines)
In Arizona, home-generated sharps may be disposed of in the regular household trash if the following safety procedures are followed:
•	Place all used needles, syringes, and sharps in a puncture-resistant, sealable container (e.g., an FDA-cleared sharps container or a heavy-duty plastic container such as a laundry detergent bottle).
•	Seal the container lid securely and reinforce it with strong tape.
•	Clearly label the container with “Not Recyclable” or “Sharps” as recommended by ADEQ guidelines.
•	Do not place sharps in recycling. Dispose of the sealed, labeled container in the regular household trash.
•	Never dispose of loose needles or syringes directly into household garbage.
For additional information, please refer to: Safe Needle Disposal – Arizona Guidelines(https://safeneedledisposal.org/states/arizona/)
Compounded Semaglutide – Off-Label Use and Disclosures
By signing below, I acknowledge and agree to the following:
•	I understand that compounded semaglutide is not approved by the U.S. Food and Drug Administration (FDA) for safety, efficacy, or manufacturing quality. It is being prescribed for off-label use in weight management and has not been formally evaluated or approved by the FDA for this indication.
•	The compounded medication is prepared by a 503A state-licensed compounding pharmacy operating under applicable state and federal regulations. Compounded semaglutide is not interchangeable with FDA-approved brands such as Ozempic® or Wegovy®, and individual results and tolerability may vary.
•	I understand that post-marketing studies and safety monitoring are ongoing, and that long-term safety, effectiveness, and outcomes of compounded semaglutide have not been fully established. There may be known and unknown risks and side effects associated with its use.
•	WildBerryMD reserves the right to change pharmacy partners at any time, without prior notice, based on availability, pricing, compliance standards, shipping delays, or other clinical or business needs.
•	Once prescribed, delivery may take approximately 7 to 10 business days. While WildBerryMD and its pharmacy partners strive to ensure timely delivery, I acknowledge that shipping delays may occur due to factors beyond their control, including supply shortages, pharmacy processing times, or carrier delays. Delivery timelines are not guaranteed.
________________________________________
2. Voluntary Participation and Telehealth Acknowledgment
By choosing to receive semaglutide therapy through WildBerryMD’s telehealth platform, I understand and agree to the following:
•	I may pause, discontinue, or adjust treatment at any time. However, I understand that abruptly stopping semaglutide may result in a return of hunger, cravings, or weight regain. I agree to consult with WildBerryMD before making any changes to my treatment plan.
•	I agree to notify WildBerryMD immediately if I experience side effects or feel unwell, and I will stop using the medication until further medical guidance is provided.
•	I understand that WildBerryMD is a wellness-focused telemedicine provider and does not provide emergency medical care or primary care services. I agree to maintain care with my primary care provider and appropriate specialists for routine, preventative, urgent, or chronic medical needs, including lab work and medication clearance as needed.
•	In the event of a medical emergency, I will call 911 or go to the nearest emergency facility. I will not rely on WildBerryMD for urgent care.
•	I am responsible for:
o	Providing accurate and complete health information, including any changes in medications, diagnoses, weight, blood pressure, or lab results.
o	Informing my other healthcare providers (e.g., PCP, surgeons, specialists) about my participation in this program and any medications or therapies I am receiving through WildBerryMD.
o	Complying with the treatment plan and lifestyle changes recommended for optimal outcomes.
________________________________________
3. Assumption of Risk and Indemnification
In consideration of receiving elective compounded semaglutide therapy via telehealth from WildBerryMD:
•	I voluntarily assume all risks associated with this treatment, including any adverse reactions, complications, or outcomes, whether known or unknown.
•	I agree to release, defend, indemnify, and hold harmless WildBerryMD, its providers, staff, contractors, affiliates, and partner pharmacies (collectively, “WildBerryMD and its Representatives”) from any and all claims, demands, damages, costs, or liabilities arising out of:
o	My participation in this compounded semaglutide weight management program, including medications, dietary recommendations, or health coaching;
o	My failure to fully disclose relevant medical history;
o	Shipment delays or changes in pharmacy partners;
o	My decision to undergo elective treatment via telehealth.
•	This indemnification does not apply to gross negligence or willful misconduct and shall be subject to limitations under applicable Arizona law.
________________________________________
4. Severability and Entire Agreement
If any provision of this agreement is determined to be invalid or unenforceable under applicable law, the remainder shall remain in full force and effect. This document represents the entire agreement between me and WildBerryMD regarding compounded semaglutide therapy and supersedes any prior verbal or written statements or agreements.
5. Patient Acknowledgment and Consent
By signing below:
•	I confirm that I have read, understood, and voluntarily agreed to all of the above terms, risks, and responsibilities related to compounded semaglutide treatment via telehealth.
•	I acknowledge that I have read, understood, and agree to the inherent risks, limitations, and terms described in the WildBerryMD Telehealth Informed Consent, which governs the delivery of all telemedicine services provided by WildBerryMD.
•	I understand this consent applies specifically to telehealth services provided by WildBerryMD.
•	I acknowledge that I have had the opportunity to ask questions and receive answers to my satisfaction.
•	I consent to initiate and continue compounded semaglutide therapy through WildBerryMD as an elective, self-pay wellness service.
•	I understand that results are not guaranteed and may vary depending on adherence, health status, and response to treatment.
•	I agree that my electronic signature is the legal equivalent of my handwritten signature.

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Weight Loss Injection Consent Form