Informed Consent
I seek weight loss treatment from American Pharmacy Marketing d/b/a eesi.com (the “Company”). I am executing this informed consent (“Informed Consent”) to verify and confirm information provided by the Company from its website and my discussion with my treating provider regarding my weight loss treatment. I understand the treatment to which I am consenting. The medically acceptable alternatives have been explained to me, which include change in eating habits, lifestyle, diet and exercise to avoid taking medicine. I also understand the substantial risks and hazards of the treatment as recognized the relevant medical community.
I am here for my own purposes and not on behalf of a third-party. I understand that I am a participant in the decision-making process and I am free to decline services or treatments at any time. I agree to alert a Company representative, if, at any time, I have any lack of understanding of the risks, benefits and alternatives of my treatment, and inquire of staff for further explanation until I have a full understanding before giving consent.
The treatment I am consenting to is at home, self-injection of GLP-1 Medication (Tirzepatide or Semaglutide) based on my treating provider’s evaluation of me based upon the diagnostic criteria, including a Body Mass Index of 30 or above, for which my treating provider has determined that GLP-1 Medication injections are a medically appropriate and necessary medication to treat my condition, and that I meet Florida’s criteria for receiving weight loss medical treatment.
The treatment will include a physician providing a prescription for GLP-1 Medication that will be filled by a licensed pharmacy and sent directly to my home. The package will include materials and instructions for preparation and self-injection of a specified dose of GLP-1 Medication subcutaneously (under the skin). I understand that if I have any issues, I should contact the Company medical professional which contact information has been provided to me.
The risks of this treatment include:
Thyroid tumors. Let a medical professional know quickly if you have a lump or swelling in your neck or throat, trouble swallowing or breathing, or if your voice gets hoarse.
Pancreatitis (swelling of the pancreas). Let a medical professional know quickly if you have sudden and severe stomach pain, chills, constipation, nausea, vomiting, fever, or lightheadedness.
Gaseous stomach pain, indigestion, recurrent fever, severe nausea or vomiting, stomach fullness, or yellow eyes or skin. Let a medical professional know quickly as these may be symptoms of gallbladder problems (eg, cholelithiasis, cholecystitis).
Diabetic retinopathy. Let a medical professional know if you have blurred vision or any other changes in vision.
Hypoglycemia (low blood sugar), low blood sugar is not caused by GLP-1 Medication, but can occur when you use GLP-1 Medication with other medicines, including insulin or sulfonylureas, that can lower blood sugar.
Serious allergic reactions, including anaphylaxis and angioedema, which can be life-threatening and require immediate medical attention. Contact a medical professional doctor immediately if you have a rash, itching, hoarseness, trouble breathing, trouble swallowing, or any swelling of your hands, face, mouth, or throat while you are using this medicine.
Acute kidney injury. Let a medical professional know right away if you have a bloody urine, decreased urine output, muscle twitching, nausea, rapid weight gain, seizures, stupor, swelling of the face, ankles, or hands, or unusual tiredness or weakness.
I have read and agree to the Informed Consent as well as the Privacy & Terms & Conditions.