Patient Informed Consent & Program Waiver

Solix Health Weight Loss Program · Effective Date: [INSERT DATE]

This Patient Informed Consent & Program Waiver (“Waiver”) is provided to ensure you understand the medical, financial, and legal aspects of the Solix Health Weight Loss Program (the “Program”). Please read it in full. You will be asked to sign it (electronically and/or in writing) before any prescription is issued.

1. Acknowledgment of the Nature of the Program

I understand that the Program is a medical service delivered by New Jersey–licensed providers via telehealth. I understand that:

• The Program fees ($100 initial consultation and $100/month) are paid for clinical care, evaluation, and prescribing services only.
• The Program fees do not cover any medication, supplement, device, lab test, or other product. I am financially responsible for those items separately.
• Enrollment does not guarantee that I will receive a prescription, that any specific medication will be available, or that any insurance will cover any portion of my care or my medications.

2. Telehealth Consent

I voluntarily consent to receive medical care via telehealth (video and asynchronous secure messaging) under the New Jersey Telemedicine and Telehealth Act, N.J.S.A. 45:1-61 et seq. I understand that:

• A physical examination may not be performed, and certain conditions cannot be safely diagnosed or treated by telehealth alone;
• My provider may decline to prescribe and may refer me for in-person evaluation if clinically indicated;
• Technology failures may delay or prevent care; in an emergency I will call 911;
• My telehealth visits become part of my permanent medical record under HIPAA.

3. Eligibility Confirmations

I confirm that:

• I am at least 18 years old;
• I currently reside in New Jersey;
• I am not currently pregnant, attempting to become pregnant, or breastfeeding (if seeking GLP-1 therapy);
• The medical history and information I have provided is accurate, complete, and current to the best of my knowledge.

4. Risks of Weight-Loss Medications — GLP-1 Receptor Agonists

If my provider determines that a GLP-1 receptor agonist (such as semaglutide or tirzepatide) is clinically appropriate for me, I acknowledge the following risks. I have read each item.

4a. Common side effects

• Nausea, vomiting, diarrhea, constipation, abdominal pain;
• Decreased appetite, fatigue, headache, dizziness;
• Injection-site reactions (redness, itching, bruising).

4b. Serious side effects (may require immediate medical attention)

• Pancreatitis — severe, persistent abdominal pain, sometimes radiating to the back;
• Gallbladder disease including gallstones and cholecystitis;
• Acute kidney injury, often related to severe dehydration from vomiting/diarrhea;
• Severe allergic reactions, including anaphylaxis and angioedema;
• Hypoglycemia, especially in patients also taking insulin or sulfonylureas;
• Diabetic retinopathy complications in patients with type 2 diabetes;
• Suicidal ideation or worsening depression reported in some patients (FDA monitoring);
• Gastroparesis (delayed stomach emptying) which can complicate anesthesia;
• Ileus / bowel obstruction (post-marketing reports).

4c. Pregnancy & lactation

GLP-1 medications may cause fetal harm and are not recommended in pregnancy. I will use effective contraception while on therapy. I will inform my provider immediately if I become pregnant. If I am breastfeeding, I will discuss the unknown risks with my provider before starting therapy.

4d. Anesthesia / surgery

Because GLP-1 medications slow stomach emptying, I will inform any anesthesiologist or surgeon that I take a GLP-1 well in advance of any procedure. My provider may instruct me to hold doses before surgery.

4e. Off-label and compounded use

I understand that:

• Some GLP-1 medications may be prescribed off-label for weight management.
• Compounded versions of semaglutide or tirzepatide are not FDA-approved; the FDA has not reviewed compounded products for safety, efficacy, sterility, potency, or purity.
• Compounded ingredients may differ from the FDA-approved counterparts (for example, compounded semaglutide may use a salt form rather than the base form).
• The manufacturer of the FDA-approved product has not endorsed compounded versions.
• I have the option to discuss using only an FDA-approved branded medication, subject to availability and cost.

5. Alternatives to Treatment

I understand alternatives include: lifestyle modification alone (diet, exercise, behavioral therapy); other prescription weight-loss medications; bariatric surgery referral; and no treatment at all. I have had the opportunity to discuss alternatives with my provider.

6. No Guarantee of Results

I understand that weight-loss results vary. Solix Health does not guarantee any specific weight loss or freedom from side effects. Outcomes depend on adherence and individual factors.

7. My Responsibilities

I agree to:

• Take any prescribed medication exactly as instructed; not share, sell, or give it to anyone else;
• Promptly report side effects, hospitalizations, pregnancy, or new diagnoses;
• Attend scheduled monthly visits;
• Complete required lab work when ordered;
• Inform every other healthcare provider I see that I am taking a GLP-1 (especially anesthesiologists, surgeons, ER staff, and obstetricians);
• Store and dispose of medications safely (refrigeration, sharps containers).

8. Financial Acknowledgment

I authorize Solix Health to charge my payment method:

• $100.00 at enrollment for the initial consultation;
• $100.00 per month automatically thereafter, with a 3-month minimum commitment;
• Continuing automatically at $100/month after the minimum until I cancel.

I understand that if I cancel before three (3) monthly fees have been successfully charged, the unpaid balance of the 3-month minimum will be charged to my payment method on file as a single final transaction. I have read and accept the full Terms of Service including the cancellation policy.

I understand medication and lab fees are separate and are not part of the Program fee.

9. Release & Acknowledgment

I voluntarily and knowingly enter into the Program. To the fullest extent permitted by New Jersey law, I release Solix Health and its providers, employees, and contractors from claims arising from the non-medical aspects of the Program, including (a) outcomes that depend on my own adherence; (b) actions or pricing decisions of any pharmacy or laboratory; (c) the FDA-approval status of any compounded medication that I knowingly accept; and (d) interruptions caused by technology failures.

10. HIPAA Acknowledgment

I have received and reviewed the Solix Health Notice of Privacy Practices and understand my health information will be used and disclosed for treatment, payment, and healthcare operations as permitted by HIPAA.

11. Voluntary Participation & Right to Withdraw Care

I understand that I may withdraw consent for treatment at any time and may end the provider–patient relationship; however, withdrawal does not terminate my financial obligations under the Terms of Service (Section 9 of the Terms governs cancellation).

12. Patient Statement

I have read this Waiver in full, or it has been read to me. I have had an opportunity to ask questions and have my questions answered to my satisfaction. I understand the risks, benefits, alternatives, and financial terms of the Program. I voluntarily consent to enroll.

Drafting note (delete before publishing): Have a New Jersey–licensed healthcare attorney review this Waiver. Ensure your provider counter-signs it during or after the consultation. Confirm that your e-signature workflow stores the signed PDF, IP, and timestamp in the patient’s medical record. Consider adding medication-specific consents (separate semaglutide vs. tirzepatide forms) if you wish to be more granular.