An informed consent, GLP-1 agonist form documents that a patient understands the benefits, risks, and alternatives of GLP-1 receptor agonist therapy such as semaglutide or tirzepatide before starting treatment. Medical spas and weight management clinics use it to confirm patients accept the therapy, including its off-label or compounded use, and to record their agreement. This template is a starting point, so confirm wording with your own compliance or legal counsel.
What does a GLP-1 agonist informed consent form include?
The form walks the patient through the medication, what to expect, and the decision they are agreeing to. Common sections include:
- Medication description. Names the GLP-1 agonist prescribed, such as semaglutide or tirzepatide, and how it supports weight management and blood sugar control.
- Expected benefits. Describes potential results like appetite reduction and gradual weight loss, and notes that outcomes vary and are not guaranteed.
- Risks and side effects. Lists common effects like nausea, vomiting, and diarrhea, along with serious risks such as pancreatitis, gallbladder problems, and low blood sugar.
- Contraindications and warnings. Covers the thyroid C-cell tumor warning and conditions like personal or family history of medullary thyroid carcinoma, MEN 2, and pregnancy.
- Off-label or compounded use. Discloses when a compounded or off-label formulation is used and confirms the patient understands its regulatory status.
- Alternatives. Notes other treatment options, including diet and exercise, other medications, and choosing no treatment at all.
- Dosing and administration. Explains injection instructions, dose titration, and the importance of following the prescribed schedule and follow-up visits.
- Patient acknowledgment and signature. Captures the patient's confirmation that questions were answered and their dated signature agreeing to proceed.
How to administer the GLP-1 agonist informed consent form
- Send the form to the patient ahead of the visit so they have time to read the risks and prepare questions.
- Have the patient review each section and complete their medical and health history where the form asks for it.
- Give the provider time to answer questions and discuss risks, benefits, and alternatives before signing.
- Collect the patient's e-signature to confirm they understand and agree to start therapy.
- Store the signed consent securely with the patient's records so it is available if needed later.
- Re-consent returning patients when the medication, dose, or formulation changes, or per your practice policy.
Who uses the GLP-1 agonist informed consent form?
- Medical spas. Aesthetic and wellness practices offering GLP-1 weight management programs use it before starting patients on therapy.
- Weight management clinics. Dedicated weight loss programs document consent for injectable GLP-1 medications and compounded formulations.
- Prescribing providers. Physicians, nurse practitioners, and physician assistants use it to record the informed consent discussion.
- Front desk and clinical staff. Team members send the form, confirm it is completed, and file the signed copy with the patient's records.
Digital vs paper GLP-1 agonist informed consent form
| Paper | Zentake digital |
|---|---|
| Handwriting can be hard to read and fields left blank | Clear typed responses with required fields enforced |
| Filled out in the waiting room, adding delay | Completed before the visit on the patient's own device |
| Ink signature on a printed page | Legally valid e-signature captured and time-stamped |
| Paper stored in folders or scanned by hand | Encrypted, HIPAA-compliant storage in one place |
| Reprinted whenever the medication or dose changes | Updated and re-sent in a few clicks |
| Staff sort, file, and chase missing forms | Less manual handling and fewer missing consents |
How Zentake helps with the GLP-1 agonist informed consent form
- E-signatures. Capture legally valid, time-stamped electronic signatures so consent is documented before treatment begins.
- Custom form builder. Use the custom form builder to match consent wording to your medication, formulation, and state requirements.
- Before the visit. Forms are ready before the appointment for medical spa practices, so patients arrive with consent already reviewed and signed.
- In-clinic tablets. Patients who did not complete the form at home can finish it on an in-clinic tablet when they arrive.
- HIPAA compliant. Data is encrypted and a signed BAA is included on every plan, keeping consent records protected.
References
GLP-1 receptor agonist labeling, including the boxed warning for thyroid C-cell tumors and contraindications such as medullary thyroid carcinoma and MEN 2, is published by the U.S. Food and Drug Administration in the approved prescribing information. Informed consent requirements for treatment are governed by state medical practice laws and vary by jurisdiction.
This template is a general starting point and not legal advice. Practices should confirm the required disclosures and wording with their own compliance or legal counsel, especially for compounded or off-label formulations.
Last updated: August 2026