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BMI Consent

The traditional use of weight loss medications is for individuals with a BMI of 30 and above or to those who are overweight who have associated health conditions. Using it for someone with a BMI range (27-29) without an accompanying health condition is termed "off-label." Using a medication "off-label" refers to the practice of prescribing a drug for a purpose, age group, dosage, or form of administration that is not included in the approved labeling by regulatory agencies like the U.S. Food and Drug Administration (FDA). While a medication undergoes rigorous testing for specific uses before receiving approval, healthcare providers may discover through clinical experience or research that it can be effective for treating other conditions. There may be benefits such as weight reduction for individuals within your range. If you agree to this off-label use, it's crucial to follow the prescribed regimen and report any concerns. Please discuss any questions with us.


What is your gender at birth?

Are you currently pregnant, breastfeeding or planning to become pregnant?

Read the following for more information
about this product and its potential side effects.

The FDA says that these medications may pose a risk to the developing fetus (baby) if you get pregnant while taking it. Oral contraception is not enough because this medication can
interfere with its effectiveness. For birth control you must use condoms, an IUD, or an implanted device. The FDA officially recommends that for the first month after starting a weight loss
medication, and for the first month after each dose escalation,
continue using your oral contraception and add a barrier method of contraception (such as condoms) to prevent pregnancy.

Alternatively, you can switch to a non-oral contraceptive method (such as an IUD or implant) before starting your medication. When you stop the medication, you must continue using a backup method (like condoms) for two months after stopping to allow the medication to fully leave your system before getting pregnant. Similarly, it is not known to be safe in breastfeeding. If you are breastfeeding, consult your doctor for safe weight loss options.

All current or past medical conditions:

All or current past medical conditions:

Things to know about your gallbladder:

Read the following for more information about this product and its potential side effects.

Gallbladder disease information:

You noted that you have had gallbladder stones, problems, or your gallbladder removed. This medication is still a good option. However, this medication can affect the way the body handles fats and bile. Without a gallbladder, the body's ability to store and release bile is altered. Bile is crucial for the digestion and absorption of fats. This medication may increase the likelihood of gastrointestinal side effects in these individuals because it can alter fat metabolism and bile flow. This can lead to symptoms such as diarrhea and stomach pain.


Risks of gallbladder disease and weight loss medication

Additionally, medications that affect digestion and appetite, like this medication, might alter the absorption and metabolism of other nutrients (like fat soluble vitamins such as vitamin A, D, E, and K) and medications. This is particularly important for those without a gallbladder, as their digestive system already operates differently from those with a functioning gallbladder. If you wish to move forward, it is important to eat smaller and more frequent meals. In addition, to ensure that you're receiving enough vitamins, you should avoid processed foods and eat lots of vegetables, as well as considering the use of a multi-vitamin unless told by your provider to avoid these for other reasons.


By clicking “Next” you affirm that you have read and understood the above and want to continue

Please tell us more about your medical condition(s) that you selected

Please identify all your current medical conditions

Please list all your current medications including dosages

Please list all of your known allergies

Have you had a gastric bypass in the past 6 months?

Are you allergic to any of the following?

Do you take any of the following medications?

● Insulin

● Glimepiride (Amaryl)

● Glipizide (Glucotrol and Glucotrol XL)

● Glyburide (Micronase, Glynase, and Diabeta)

● Sitagliptin

● Saxagliptin

● Linagliptin

● Alogliptin

Are you currently, or have you in the past two months, taken any of the following medications?

Have you experienced side effects from your current medication?

Please describe the side effects that you've experienced

Which medication and dose most closely matches your most recent dose?

How would you like to continue your treatment?

Do you have a picture of your current prescription? We need this photograph in order to validate your current dosage.

Please upload a picture of the prescription or bottle of your current GLP-1 medication

We need this photograph in order to validate your current dosage

Identity Verification

Upload a photo of a valid government-issued ID such as a driver’s license or passport which has your name and date of birth clearly visible. If applicable, upload a photo of the front and the back. Make sure the photo is clear and legible.

Full Body Image

Please upload two full body photos to assist in your assessment – one facing directly at the camera and one in profile. Wear tight clothing. Make sure your body shape and face are clearly visible.

What other information or questions do you have for the doctor?

Truthfulness Consent

Please attest to the following confirming that all information you have provided to us is true and complete.

Consent: I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.

Asynchronous Telemedicine Informed Consent Thank you for choosing Beluga Health, P.A. (“Beluga”)! You are viewing this form because you have elected to engage in asynchronous telemedicine visits with a Beluga healthcare practitioner. Your practitioner is a board-certified physician licensed in your state. By clicking “I Agree,” I ACKNOWLEDGE I HAVE READ AND UNDERSTAND THE TERMS PRESENTED BELOW, AND UNDERSTAND THE RISKS AND BENEFITS OF ASYNCHRONOUS TELEMEDICINE, AND BY ACCEPTING THESE TERMS OF USE I HEREBY GIVE MY INFORMED CONSENT TO PARTICIPATE IN ASYNCHRONOUS TELEMEDICINE UNDER THESE TERMS. What is Telemedicine? Telemedicine is the delivery of healthcare services, including examination, consultation, diagnosis, and treatment, through electronic communication technologies when you (the patient) are located in a different location than your healthcare practitioner. Beluga allows you to receive treatment from a healthcare practitioner without having to travel to another location or schedule a separate appointment and helps you avoid long wait times that you might otherwise experience at an in-person visit. What is Asynchronous Telemedicine? Asynchronous telemedicine is one way to deliver telemedicine. Asynchronous communication is often referred to as “store-and-forward” communication, where participants submit and collect data at different times. An example of asynchronous communication is a telemedicine encounter with a healthcare practitioner that involves sending photos, video, or other communications via email or text message. “Asynchronous” means “not occurring at the same time” and is different from “synchronous” telemedicine, which generally includes visits conducted in real-time between patients and healthcare practitioners through audio or video means (e.g., live phone calls or video-conferencing). Healthcare practitioners may use asynchronous telemedicine to aid in diagnoses and medical consultations when live communication or face-to-face contact is not possible or necessary. Beluga’s platform (“Platform”), in particular, allows for the following asynchronous telemedicine services: 1) text-based healthcare practitioner-patient interactions through short message service (“SMS”) and multimedia messaging service (“MMS”) communications; and 2) secure information collection through asynchronous store-and-forward patient questionnaires. What are the Possible Risks to Using Asynchronous Telemedicine? As with any medical treatment, there are potential risks associated with the use of asynchronous telemedicine. Beluga believes that the likelihood of these risks materializing is very low. These risks may include, without limitation, the following: • Delays in medical evaluation and consultation or treatment may occur due to deficiencies or failures of the equipment or the Internet, which may include poor data quality, Internet outages, or other service interruption issues. You may reschedule the visit with your healthcare practitioner should these interruptions occur. • Security protocols could fail, causing a breach of privacy of personal medical information. • Because Beluga does not have access to your complete medical records, if you do not disclose to your healthcare practitioner a full list of your medical history including diagnoses, treatments, medications/supplements, and allergies, adverse treatment, drug interactions or allergic reactions, or other negative outcomes may occur. • Asynchronous telemedicine services are NOT emergency services and your Personal Data (as defined in the Beluga Privacy Policy) WILL NOT BE MONITORED 24/7. If you think you are experiencing a medical emergency, CALL 911 IMMEDIATELY. THE CARE YOU RECEIVE WILL BE AT THE SOLE DISCRETION OF THE HEALTHCARE PRACTITIONER WHO IS TREATING YOU, WITH NO GUARANTEE OF DIAGNOSIS, TREATMENT, OR PRESCRIPTION. THE HEALTHCARE PRACTITIONER WILL DETERMINE WHETHER OR NOT THE CONDITION BEING DIAGNOSED AND/OR TREATED IS APPROPRIATE FOR THE CARE PROVIDED THROUGH AN ASYNCHRONOUS TELEMEDICINE ENCOUNTER VIA THE PLATFORM. Your Rights and Acknowledgements: • You have the same privacy rights via asynchronous telemedicine that you would have during an in-person visit. Dissemination of any identifiable images or information from the asynchronous telemedicine visit to researchers or other entities will not occur without your written consent. For more information about how we protect your privacy, please read the Beluga Privacy Policy here. • Asynchronous telemedicine may involve electronic communication of your personal medical information to healthcare practitioners who may be located in other areas, including out of state. • You understand that you may expect the anticipated benefits from the use of asynchronous telemedicine, but that no results can be guaranteed or assured. • You understand that all information submitted to Beluga via text message and entered by your healthcare practitioner in the Beluga Platform will be part of your medical record and available to you by emailing [email protected]. This information will have the same restrictions on dissemination without your consent. • You understand that your healthcare practitioner’s initial text message to you will include his/her name and credentials, and this will be recorded in the Beluga Platform as part of your medical record. • You understand you may withdraw your consent and delete your patient profile at any time by emailing [email protected]. • You understand that your healthcare information may be shared with other individuals in accordance with the Beluga Privacy Policy and regulations or laws in state or territory in which you are located. • You further understand that your healthcare information may be shared in the following circumstances: o When a valid court order is issued for medical records. o Reporting suspected abuse, neglect, or domestic violence. o Preventing or reducing a serious threat to anyone's health or safety. Call/Email/Text Messaging Consent: You expressly consent to allow Beluga or its healthcare practitioners to call, email, or text you (via SMS and/or MMS) with or regarding Personal Data (as defined in the Beluga Privacy Policy), appointments, or similar matters related to your telemedicine encounters using the contact information you have provided. Any calls or texts to you may be placed using an auto-dialer or a pre-recorded or artificial voice, even if your number is on a do-not-call list. Your phone carrier’s normal rates may apply. This is consent, not a condition of purchase. You may revoke this consent at any time by emailing us at [email protected]. This Asynchronous Telemedicine Informed Consent is valid during your entire treatment with Beluga.

Consent (GLP-1 and GLP-1/GIP)

Indication for Use

You are requesting treatment with a GLP-1 (Ozempic, Wegovy, or compounded semaglutide) or GIP/GLP-1 receptor agonist (Mounjaro, Zepbound, or compounded tirzepatide) medication as part of your treatment plan for the management of weight or obesity. These medications work by mimicking the action of incretin hormones, which help regulate blood sugar levels, promote feeling full, and reduce food intake.

Potential Benefits

  • Weight loss or weight management

  • Improved blood glucose control

  • Reduced cardiovascular risk

  • Potential improvement in overall metabolic health

Potential Side Effects

While these medications can be beneficial, they may also cause side effects.  Although not common, these medications can result in emergency room visits, hospitalizations, or even death. Common and serious side effects include, but are not limited to:

  • Common Side Effects:

    • Nausea

    • Vomiting

    • Diarrhea

    • Constipation

    • Decreased appetite

    • Indigestion

  • Serious Side Effects:

    • Pancreatitis (inflammation of the pancreas)

    • Hypoglycemia (low blood sugar), especially when used with other diabetes medications

    • Gallbladder disease (e.g., gallstones)

    • Kidney problems

    • Allergic reactions (e.g., rash, itching, swelling)

    • Gastroparesis (paralysis of the bowels)

Risks and Considerations

  • Pancreatitis: There is a risk of developing pancreatitis. If you experience severe abdominal pain, nausea, or vomiting, you should contact your healthcare provider immediately.

  • Thyroid Tumors: Animal studies have shown an increased risk of thyroid tumors with certain GLP-1 medications. Although this has not been confirmed in humans, please inform your healthcare provider if you have a history of thyroid cancer.

  • Hypoglycemia: When taken with other diabetes medications, particularly insulin or sulfonylureas, there is a risk of low blood sugar. It is important that your provider knows if any of these medications are added to your regimen. 

  • Kidney Function: This medication may affect kidney function, particularly in patients with existing kidney disease. Regular monitoring of kidney function may be required.

Monitoring and Follow-up

You will require regular follow-up visits to monitor your response to the medication and to assess for any side effects. We may intermittently ask for full-body selfie images to ensure that your reported weight is consistent.

I acknowledge the potential benefits, risks, and side effects of GLP-1 or GIP/GLP-1 receptor agonist medications. I understand the importance of regular monitoring and follow-up appointments. I consent to the use of GLP-1 or GIP/GLP-1 receptor agonist medications as part of my treatment plan for overweight or obesity.

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