[PRACTICE NAME]
[ADDRESS LINE 1]
[CITY, STATE ZIP]
Phone: [PHONE] | Fax: [FAX]
Informed Consent for GLP-1 Receptor Agonist Therapy
BOXED WARNING - Thyroid C-Cell Tumors

WARNING: RISK OF THYROID C-CELL TUMORS

In rodent studies, GLP-1 receptor agonists including semaglutide and tirzepatide caused dose-dependent and treatment-duration-dependent thyroid C-cell tumors (adenomas and carcinomas). It is unknown whether GLP-1 receptor agonists cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans.

GLP-1 receptor agonists are contraindicated in patients with:

Counsel patients regarding the potential risk for MTC and symptoms of thyroid tumors (neck mass, dysphagia, dyspnea, persistent hoarseness).

Patient Name:
Date of Birth:
Date:
Medication Prescribed:
Starting Dose:
What is GLP-1 Receptor Agonist Therapy?
GLP-1 (glucagon-like peptide-1) receptor agonists are medications that mimic the effects of a natural hormone that helps regulate blood sugar and appetite. Common GLP-1 medications include:
Expected Outcomes

Weight Loss Expectations:

Medication Average Weight Loss (Clinical Trials) Timeline
Semaglutide 2.4mg ~15% of body weight 68 weeks
Tirzepatide (max dose) ~20-25% of body weight 72 weeks
Liraglutide 3.0mg ~5-10% of body weight 56 weeks

Note: Individual results vary significantly. These are average results from clinical trials; your results may differ.

Important: Weight regain is common if medication is discontinued without sustained lifestyle changes.

Gastrointestinal Side Effects

GI side effects are very common, especially during dose escalation:

Tips to minimize GI side effects:

Serious Risks and Warnings

The following serious adverse events have been associated with GLP-1 therapy:

Contraindications

Do NOT use GLP-1 receptor agonists if you have:

Important Considerations for Women
Anesthesia and Surgical Procedures

IMPORTANT: Due to delayed gastric emptying, inform all healthcare providers that you are taking a GLP-1 medication before any procedure requiring anesthesia or sedation.

Patient Acknowledgments
Please initial each statement:
I have read and understand the BOXED WARNING regarding thyroid C-cell tumors
I confirm I do NOT have a personal or family history of medullary thyroid carcinoma or MEN 2
I understand the common GI side effects and how to manage them
I understand the risk of pancreatitis and will seek immediate care for severe abdominal pain
I understand weight regain commonly occurs when medication is discontinued
I will inform all healthcare providers about this medication, especially before surgery or procedures
If applicable: I am not pregnant, not planning pregnancy, and using appropriate contraception
I agree to follow the dose titration schedule and attend follow-up appointments
I understand this medication is most effective when combined with diet and exercise
Patient Signature
Date
Patient Printed Name
Prescriber Signature
Date
Prescriber Printed Name & Credentials

This consent form is valid for 12 months from the date of signature unless revoked earlier by the patient.

A copy of this signed consent will be provided to the patient and maintained in the medical record.

Template provided by PeptidePrescriber.com - For educational purposes only - Review with legal counsel before use