Weight Loss Programme

Medical History

Consent To Treatment: GIP and/or GLP-1 RA Weight Loss Injections

Informed Consent Instructions:

This is an informed consent document to provide written information about the above named treatment regarding risks, benefits, and alternatives. It is important that you understand the information

provided to you prior to proceeding with this treatment; please ask your healthcare professional any/all questions prior to signing this consent form.

I consent to treatment by Harpreet Thiara (Mpharm) Independent prescribing pharmacist (2211778) specialising in diabetes and weight loss at Tiara Clinics using Tirzepatide (GIP/GLP-1 RA)/Pyridoxine (B6) (Mounjaro brand) injections for elective chronic weight management treatment.

Treatment benefits will vary by individual, but may include: reduced appetite, feeling a sense of fullness for longer durations after eating (delayed gastric emptying), and increased fat-burning mechanisms which may result in weight loss. Additional therapeutic benefits related to weight management may include: improved blood sugar levels and reduced risk of adverse cardiovascular events.

Purpose of Treatment and General Information:

What is Tirzepatide Weight Management Treatment?

Tirzepatide weight management injections are used for weight loss along with a diet and exercise plan. These injections are delivered beneath the surface of the skin (subcutaneously) for chronic weight management in adults with obesity (BMI >30) or who are overweight (BMI >27)

with at least one weight-related condition, including high blood pressure, diabetes type 2, and/or high cholesterol or other factors upon consultation with prescriber.

Tirzepatide mimics both GIP and GLP-1 receptor agonist hormones, which trigger insulin creation, sensation of fullness, and appetite reduction. Additional treatment benefits associated with these weight loss injections may include:

improved A1C and blood sugar levels by increasing insulin (a hormone that lowers blood sugar levels) and inhibiting

glucagon (a hormone that raises blood sugar); improved blood pressure; reduced risk of major adverse cardiovascular events.

What To Expect During Treatment:

Your treatment provider will begin with an online consultation that includes discussing weight journey, bloods, medical history, lifestyle, BMI and other factors to review your health and to ensure you are a good candidate for weight loss injections. You will be counselled on nutrition, supplements and exercise recommendations to be used along with Tirzepatide injections for chronic weight management, including reducing calories and increasing physical activity.

You will be taught how to perform these injections at home just below the surface of the skin (subcutaneously) and will be prescribed a dosage that is adjusted for your individual needs, in accordance with your treatment plan. There is no downtime associated with this treatment. You may feel minor discomfort during the injection, similar to an insulin

injection.

Common side effects include: nausea, vomiting, diarrhea, indigestion, abdominal pain, constipation,

fatigue, and dizziness. Multiple injections will be needed over the course of months to achieve desired results.

Dosing adjustments will be made by your treatment provider based on your body's response and any side effects you're experiencing.

Treatment Regimen: Typical treatment regimen includes an initial series of weekly injections for 30 days, including follow-up and dose review. You will be required to consult your prescriber via zoom for follow-ups and dose adjustments until you've reached your weight loss goals.

Maintenance: Once you have achieved your weight loss goal, you may be

weaned down to lower dosing Tirzepatide at specified intervals.

Treatment Benefits:

Tirzepatide/Pyridoxine injection benefits may include:

Weight reduction and/or weight management

Improved blood sugar

Reduced risk of adverse cardiovascular events related to obesity

Possible Risks and Side Effects:

Possible side effects/risks of Tirzepatide/Pyridoxine Weight Management Treatment may include:

1. General Side Effects: I understand there is a risk of discomfort, pinpoint bleeding, pain at the injection site, bruising, allergic reaction, damage to deeper structures, or gastrointestinal side effects that may occur.

2. Gastrointestinal Upset: The most common side effects of treatment include: Nausea, vomiting, diarrhea, constipation, indigestion, belching, feeling bloated, and abdominal pain. Slow titration of dosing adjustments may help prevent these side effects, or dosing adjustments may be required if side effects persist. Your treatment provider can provide you with medications and/or recommendations to help alleviate these side effects, including suggesting eating slowly, eating bland foods, avoiding greasy foods, and avoiding lying down immediately after eating.

3. Fatigue, Dizziness, and Headache: Some patients experience fatigue, dizziness, and/or headache, which may be a result of low blood sugar. If you experience these symptoms, please discuss this with your treatment provider.

4. Low Blood Sugar: There is an increased risk of low blood sugar (hypoglycemia), especially in patients with type 2

diabetes taking medications such as insulin or sulfonylureas. Symptoms may include: dizziness, headache, lightheadedness, rapid heartbeat, mood changes, irritability, weakness, shakiness, slurred speech, confusion, or hunger. Talk to your healthcare provider about how to recognize and treat low blood sugar. If you have diabetes type 2, you should check your blood sugar as directed.

5. Increased Heart Rate: You may experience an increased heart rate while at rest. Please contact your treatment provider if you experience your heart racing or if you feel a pounding sensation in your chest that lasts for several minutes or longer.

6. Allergic Reaction or Hypersensitivity: Although rare, allergic reactions or serious hypersensitivity may occur.

Signs of allergic reaction may include: hives, difficulty breathing, swelling of your face, lips, tongue, or throat; additional

treatment may be necessary should an allergic reaction occur. Please call 999.

7. Runny Nose and Sore Throat: Common side effects include a runny nose and sore throat. Tell your treatment

provider if these symptoms persist or become bothersome.

8. Bleeding/Bruising/Redness: It is possible to experience minor pinpoint bleeding during and after injection. Bruising

in soft tissues may occur, as well as minor redness or swelling.

9. Infection: Although rare, if an infection occurs as a result of treatment at injection site, additional treatment including

antibiotics or an additional procedure may be necessary.

10. Pancreatitis: Inflammation of the pancreas (pancreatitis) may occur. If you experience persistent severe pain in

your stomach, with or without vomiting, please contact your treatment provider right away.

11. Gallbladder Inflammation and/or Gallstones: You may experience gallbladder issues, including gallstones.

Signs/symptoms of gallbladder inflammation and/or gallstones include: pain in your upper stomach, yellowing of skin

and/or eyes, clay-colored stools, and fever. Please contact your treatment provider right away if you experience these

symptoms. Some gallbladder issues may required additional treatment incurred at your expense, and which may

include surgical intervention and/or hospitalization.

12. Gastrointestinal Blockage or Disease: Although rare, there is a risk of stomach blockage (known as a an ileus) resulting from decreased intestinal movement of food and fluids. Symptoms include persistent, unrelieved constipation, stomach cramping and swelling, loss of appetite, inability to pass gas, and vomiting. An ileus can be serious and life

threatening if left untreated; treatment may include hospitalization and/or surgery incurred at your expense.

13. Dehydration and Acute Kidney Injury and/or Renal Impairment: There is a potential risk for dehydration leading to acute kidney injury and/or worsening renal impairment due to adverse gastrointestinal reactions (nausea, vomiting, diarrhea). It is important to drink adequate fluids to help reduce your risk of dehydration, which may cause kidney impairment.

14. Thyroid C-cell Tumors: There is a potential risk for thyroid C-cell tumors when taking Tirzepatide. Please report any signs/symptoms of thyroid tumors to your treatment provider, including: persistent hoarseness, shortness of breath, mass in neck, and/or difficulty swallowing.

15. Changes in Vision: Patients with diabetic retinopathy may experience changes in vision while taking Tirzepatide.

This may be caused by a rapid improvement in glucose control, which could lead to temporary worsening of retinopathy, however, the effect of long-term glycemic control on diabetic retinopathy has not yet been studied. Please report any changes in vision to your treatment provider.

This list is not exhaustive of all possible risks associated with Tirzepatide/Pyridoxine weight management treatment, as there are both known- and unknown- side effects and risks associated with any medication or treatment.

Tirzerpatide injections are contraindicated in those who:

are:

pregnant or are breastfeeding

have ever had Medullary Thyroid Cancer (MTC) (this includes a family history of MTC)

have Multiple Endocrine Neoplasia Syndrome type 2 (MEN 2)

have ever had a serious allergic reaction to Tirzerpatide or any of the ingredients in Tirzepatide, including

compound formulations, which may include: vitamin b12 and/or vitamin b6

Please tell your treatment provider if you have any other medical conditions, including the following, as Tirzepatide injections may not be suitable for you:

plan to become pregnant (you should stop Tirzepatide 2 months prior to pregnancy)

have, or have had, problems with your pancreas or kidneys

have type 1 diabetes, type 2 diabetes, or a history of diabetic retinopathy.

are taking certain medications, including: sulfonylureas or insulin

have, or have had, depression, mental health issues, and/or suicidal thoughts.

Possible Medication Interactions and/or Reduced Effectiveness

Prescription and OTC Medication, Herbal and Nutritional Supplements, and Minerals:

I understand that certain herbal products, medications, and supplements may affect the way Tirzepatide works, resulting in reduced efficacy of

treatment and/or additional side effects. Tirzepatide slows stomach emptying and can affect absorption of oral

medications medicines, which may affect the way certain medications work or the effectiveness of medications.

Pregnancy Waiver for females

I deny the possibility of being pregnant at this time. I understand that Tirzepatide may harm an unborn baby and the safety of the use of Tirzepatide during pregnancy and breastfeeding has not been studied. If I am unsure of pregnancy, I will request a pregnancy test prior to my treatment. I further acknowledge that I should stop using Tirzepatide at least 2 months prior to becoming pregnant.

I deny the possibility of being pregnant at this time and acknowledge risk of harm to unborn child while taking Tirzepatide.

No Guarantee of Results

In some situations, it may not be possible to achieve desired weight loss results. It is also possible that Tirzepatide/Pyridoxine injections may fail to produce any reduction in weight. Should complications occur, additional-

or other- treatments may be necessary. Tirzepatide/Pyridoxine injections are not a permanent solution for weight management, and must be maintained with lifestyle and diet modifications; you may also require maintenance injections to maintain desired weight. As a weight management treatment, it is recommended to allow at least 60 days

of treatment to achieve results. Duration of results is unknown and not guaranteed.

Alternative Treatments:

Alternative forms of non-surgical and surgical treatment consist of: No treatment whatsoever, diet and lifestyle

modifications, increased physical activity, other pharmaceutical weight management therapies, and bariatric surgery.

Every procedure will involve a certain amount of risk. An individual’s choice to undergo a procedure is based on the

comparison of the risk to the potential benefit. Although most patients do not experience adverse complications, you

should discuss your concerns and potential risks with your treatment provider in order to make an informed decision.

Financial Responsibility:

By signing below, I acknowledge that I understand the regular charge applies to all treatments. I understand- and agree- that all services rendered to me are charged directly to me and that I am personally responsible for payment. In the event that I am not satisfied with my results, I agree not to seek a refund for Tirzepatide treatment services rendered, as I am fully aware that there is no implied or explicit guarantee of results, as stated in the acknowledgement above. I further agree in the event of non-payment and/or reversal of payment via a credit card dispute that I initiate, I will bear the cost of collection fees, and/or court fees, and/or any reasonable legal fees resulting from such instance.

Tirzepatide (GIP/GLP-1 RA)/Pyridoxine (B6) Weight Management Treatment Consent:

By signing below, I acknowledge and agree:

I have fully disclosed on my patient form and during consultation with treatment provider any and all medications, previous complications, planned or previous surgeries, sensitivities, allergies, or current conditions

that may, or may not, affect my treatment.

I have read the foregoing informed consent for Tirzepatide/Pyroxidine Weight Management Treatment;

I agree to

the treatment and all known and unknown associated risks.

I have received and will follow all aftercare instructions.

I acknowledge that no guarantee has been given by anyone as to the results that may be obtained.

For women of childbearing age: by signing below I confirm that I am not pregnant and do not intend to become pregnant anytime during the course of this treatment and that I am not breastfeeding. Furthermore, I agree to keep my treatment provider informed should I become pregnant during the course of this treatment.

It has been explained to me in a way that I understand:

There may be alternative procedures or methods or treatments.

There are risks, known and unknown, to the procedure or treatment proposed.

I have had ample opportunity to ask any questions regarding Tirzepatide Weight Management Treatment benefits, side effects and after care, and all of my questions have been answered to my satisfaction. I believe I have

adequate knowledge to understand the nature and risk of the treatment to which I am consenting.

I understand that I may suspend or terminate my treatment at anytime by informing my medical provider.

Please get in touch with your prescriber on- tiara.aesthetics@gmail.com or on call 07379027375.

How to take your Mounjaro dose

Mounjaro comes in the form of an injectable pen, with pre-filled doses. This means you don’t need to draw up your dose before injecting it. You should take Mounjaro once weekly, at the same time and day. This makes the medication most effective and can reduce side effects by keeping the medication at a steady level.

The Mounjaro ‘KwikPen’ is a single-patient-use pen that contains 4 fixed doses, with 1 dose injected each week. That means 1 pen provides 4 weeks of treatment. Once all 4 doses have been used, you can throw the pen away.

Mounjaro can be injected into the abdomen. It may also be injected into the upper arms but only with help from someone else. Switch your injection site each week to prevent soreness and irritation.

Your used Mounjaro pen can be stored at room temperature, up to 30 degrees Celsius (°C), for no more than 30 days. Keep it away from direct light and in its original packaging. You can also store it in a fridge between 2 and 8°C and if you choose this method, it does not need to be discarded after 30 days.

Follow up appointment in 4 weeks: