Healthcare Mounjaro Consent Form

HEALTHCARE MOUNJARO CONSENT FORM

Provider Name:    Clinic/Site:

Patient Information

Date of Birth:    Gender: Male Female Other / Prefer not to say

Insurance Information

Medical History & Current Health

Chronic Conditions:

Pregnancy / Breastfeeding Status: Pregnant Trying to conceive Breastfeeding None / Not applicable

Medication Details & Administration

Indication for Mounjaro (tirzepatide): Type 2 diabetes Weight management Other:

Lot / Batch Number:    Expiration Date:

Planned Injection Site: Abdomen Thigh Upper arm

Date of Administration:    Time:

Risks, Benefits, Alternatives

The clinician has explained the nature and purpose of Mounjaro (tirzepatide), expected benefits, likely outcomes, and reasonable alternatives including no treatment and other pharmacologic or non-pharmacologic options. The patient has had an opportunity to ask questions.

Common and serious risks associated with Mounjaro include, but are not limited to:

• Nausea, vomiting, diarrhea, decreased appetite, abdominal pain.
• Acute pancreatitis (severe abdominal pain, may require hospitalization).
• Hypoglycemia, particularly when used with insulin or insulin secretagogues.
• Possible risk of thyroid C‑cell tumors observed in animal studies; relevance to humans is unknown.
• Injection site reactions, bruising, or infection.
• Severe allergic reactions including anaphylaxis.
• Gallbladder disease, acute kidney injury, or dehydration from gastrointestinal adverse effects.

The above list is not exhaustive. I acknowledge that my clinician has discussed potential risks and has answered my questions to my satisfaction.

Contraindications & Precautions

I confirm I have informed the clinician of any history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2 (MEN2), previous pancreatitis, severe gastrointestinal disease, severe renal impairment, or any known hypersensitivity to tirzepatide or any component of the formulation.

Authorization & Consent

By signing below, I authorize the administration of Mounjaro (tirzepatide) by the named provider or other authorized clinical personnel. I acknowledge that the information provided in this form is accurate to the best of my knowledge and that I have disclosed all relevant medical history and current medications. I understand that the medication has been prescribed for the indication noted and that treatment may be adjusted by my clinician as clinically indicated.

I understand my right to refuse or withdraw consent at any time prior to administration, and that withdrawing consent will not affect my access to other medical services. I consent to the recording of the administration and the inclusion of lot, dose and administration details in my medical record.

HIPAA Acknowledgment & Communications

I acknowledge that the practice will use and disclose my protected health information for treatment, payment and healthcare operations consistent with applicable privacy laws. I consent to release of information to my insurer as necessary for coverage and reimbursement for this medication and associated services.

Communications: I consent to receive appointment reminders, treatment instructions, and limited clinical communications at the following methods: Phone call SMS / Text Email

This authorization expires on:    (If left blank, authorization remains until the course of treatment is complete or until revoked in writing.)

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