This document is intended to serve as a confirmation of informed consent for compounded Semaglutide, Tirzepatide. Lipo C, B12 and Phentermine, which are prescription weight management medication.

A. Patient Informed Consent

1. I voluntarily request that the providers, Dr. Charles Tessier and/or Cynthia Champion, APRN FNP-C, and any other Healthcare Providers with CHWC treat my medical condition.

2. I have informed my provider of any known allergies, my medical conditions, medications, and social/family history.

3. I have the right to be informed of any alternative options, side effects, and the risks and benefits.

4. I understand the mechanism of action of the medication. (Decreased gastric emptying)

5. I understand how it is to be administered. (Sub Q)

6. I understand the prescription will come from a compounding pharmacy, which is not FDA-approved. I have been told that the manufacturing facility itself is FDA-monitored, along with third-party testing on the medication itself.

7. Prices may vary and change. My charge will include my time with Dr. Charles Tessier and/or Cynthia Champion, APRN FNP-C, and any other Healthcare Providers with CHWC (in-person and via communication outside of the office), supplies, and medication.

8. It has been explained to me that this medication could be harmful if taken inappropriately or without advice from the provider(s).

9. I understand this medication may cause adverse side effects (see below). I understand this list is not complete, and it describes the most common side effects and that death is also a possibility of taking this medication. I understand symptoms may be worse after there has been a change in my medication dose or when first starting the medication.

Common side effects include, but are not limited to:

• Gastrointestinal: Nausea/vomiting, abdominal pain, Diarrhea/constipation, dyspepsia, abdominal distension, eructation, flatulence, gastroenteritis, Gastroparesis GERD, gastritis, lipase increase, amylase increase.

• Neurological: Headache, dizziness

• Cardiac: Heart rate increase, Hypotension

• Endocrine: Fatigue, hypoglycemia (diabetic patients), alopecia

• Ophthalmic: Retinal disorder (diabetic patients)

• Skin: redness or pain at the injection site

Serious Reactions include, but are not limited to:

• Thyroid C-cell tumor (animal studies)

• Medullary thyroid cancer

• Hypersensitivity reaction

• Anaphylaxis

• Angioedema

• Acute kidney injury

• Chronic renal failure exacerbation

• Pancreatitis

• Cholelithiasis

• Cholecystitis

• Syncope

• Gastroparesis

B. I understand that I have the following responsibilities:

1. I agree to obtain compounded Semaglutide, Tirzepatide. Lipo C, B12 and Phentermine prescriptions only from Champion Health and Wellness providers.

a. If I want to transition to a non-compounding pharmacy or seek insurance coverage, I will inform Dr. Charles Tessier and/or Cynthia Champion, APRN FNP-C, and any other Healthcare Providers immediately.

2. Medical history: I will disclose my complete medical history, including allergies, medications, medical/surgical/social/family history to Champion Health and Wellness Clinics’ Providers.

a. Champion Health and Wellness Clinics’ Providers may ask to review, with your permission, your medical history (medications, recent lab results, pertinent imaging results).

b. I understand that if I become pregnant or start trying for pregnancy, I must stop this medication

c. I will be honest to the best of my ability about all health history requested and needed by Champion Health and Wellness Clinics’ Providers.

d. I will tell my provider any updated health information (medication, allergies, personal medical issues/surgeries/social history, or family history changes).

e. My provider can discuss my treatment plan with any co-treating pharmacist and/or healthcare provider.

f. I will always tell other providers about all the medications I am taking.

g. Champion Health and Wellness Clinics’ Providers may ask me to seek additional labs while on treatment to ensure it’s safety.

3. Directions for use: I will take my medications only as prescribed according to the directions led by Champion Health and Wellness Clinics’.

a. If I feel my medications are not effective or are causing undesirable side effects, I will contact my provider immediately for instructions.

b. I will not adjust my medications without prior instructions to do so.

c. I understand that the medication must be refrigerated.

d. I understand this medication must be self-injected in the subcutaneous tissue once weekly. I will not inject any less than 7 days unless directed by Champion Health and Wellness Clinics’ Providers.

e. I will not share needles and dispose of needles safely.

f. If I’m having trouble with medication administration, I will seek help from Champion Health and Wellness Clinics’ Providers.

g. The medication expires after 12 weeks.

4. Refills:

a. All refills are automatic unless canceled 7 days prior to next order.

b. We have automatic refills to avoid delays in refills.

5. Safety:

a. I understand it is important to keep my medication away from children (<18 years old)

b. I am the only one who will use my medication. I will not give or sell my medication to anyone else.

6. I will comply if Champion Health and Wellness Clinics’ Providers deem it appropriate to start weaning my medication or transition to maintenance dosing.

C. Discontinuation of medication: I understand that Champion Health and Wellness Clinics’ Providers may stop prescribing my medications if:

a. I am having unfavorable side effects, or it’s not working to treat my medical condition.

b. If I have been untruthful about my medical or family history

c. I do not follow through with the recommended plan of care set by Champion Health and Wellness Clinics’ Providers.

d. I do not follow any parts of “Part B: responsibilities” in this agreement.

I have read this form in its entirety. It has been explained to me. I have had the opportunity to ask questions and have all my questions answered. I understand the information above and do not have any more questions. By signing this form, I voluntarily consent to treatment and agree to the