Informed Consent and Parental Authorization:
GLP-1 Medication Treatment
for Ages 12-17
I. Purpose of Treatment
I understand that my child has been evaluated and diagnosed with obesity or overweight with a related health condition. I understand that treatment may include a comprehensive program consisting of nutrition counseling, physical activity, behavioral modification, and may include medication.
I understand that the provider is recommending treatment with a glucagon-like peptide-1 (GLP-1) receptor agonist medication, which may include Wegovy (semaglutide) or Saxenda (liraglutide). I understand these medications are FDA-approved for patients aged 12-17 when used with lifestyle modification.
I understand that no guarantee or promise has been made regarding results.
II. How these Medications Work
I understand that my child has been evaluated and diagnosed with obesity or overweight with a related health condition. I understand that treatment may include a comprehensive program consisting of nutrition counseling, physical activity, behavioral modification, and may include medication.
I understand that the provider is recommending treatment with a glucagon-like peptide-1 (GLP-1) receptor agonist medication, which may include Wegovy (semaglutide) or Saxenda (liraglutide). I understand these medications are FDA-approved for patients aged 12-17 when used with lifestyle modification.
I understand that no guarantee or promise has been made regarding results.
III. POTENTIAL BENEFITS
I understand potential benefits may include:
• Reduction in body weight or BMI
• Improvement in blood pressure, blood sugar, and cholesterol
• Reduced risk of weight-related complications (fatty liver, sleep apnea, joint pain, type 2 diabetes)
• Support for healthier lifestyle habits alongside behavioral and nutritional counseling
IV. RISKS AND SIDE EFFECTS
I understand that all medical treatments involve risks.
A. Common Side Effects (usually mild and improve over time):
I understand these may include:
• Nausea, vomiting, diarrhea, and constipation
• Stomach pain
• Decreased appetite
• Headache, fatigue
• Injection site redness or itching.
B. Serious Risks:
I understand I should seek immediate medical attention if my child experiences:
• Severe stomach pain that radiates to the back (possible pancreatitis)
• Signs of a severe allergic reaction: throat swelling, difficulty breathing, rapid heartbeat
• Inability to keep fluids down for more than 24 hours (dehydration risk)
• Mood changes, new or worsening sadness, anxiety, or thoughts of self-harm call 988 or 911 immediately)
C. Important Safety Warning:
I understand that GLP-1 medications carry an FDA black box warning. GLP-1 medications have caused thyroid tumors in animals. It is unknown whether this risk applies to humans. These medications must not be used if your child or any blood relative has a history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia type 2 (MEN 2).
D. Long-term Data:
I understand that long-term safety data in adolescents beyond about 1-2 years is limited.
V. CONTRAINDICATIONS
I understand that this medication is generally not appropriate for patients with:
• Personal or family history of medullary thyroid carcinoma or MEN 2
• History of pancreatitis
• Type 1 diabetes
• Active restrictive eating disorder (anorexia nervosa, ARFID)
• Current pregnancy
I understand that I must inform the provider if any of the above apply.
VI. TREATMENT AND MONITORING
I understand that safe treatment typically includes:
• Baseline laboratory testing
• Follow-up visits (e.g., 4, 8, 12 weeks, then periodically)
• Ongoing weight, height, and BMI monitoring
• Periodic laboratory reassessment
• Mental health and eating disorder screening
I understand that failure to complete recommended monitoring may result in modification or discontinuation of treatment with GLP-1 medications.
VII. MEDICATION DETAILS
Medication Prescribed:
☐ Semaglutide (Wegovy®)
☐ Liraglutide (Saxenda®)
☐ Other: __________________
I understand that dosing and titration will be determined by the provider. I understand that medication must be stored and handled according to instructions, including refrigeration when required. I understand that used needles must be disposed of safely in a sharps container.
VIII. TELEHEALTH CONSENT
I understand that care may be provided in whole or in part through telehealth (video, phone, or electronic communication).
I understand that:
• Telehealth has limitations compared to in-person exams
• My child must be physically located in a state where the provider is authorized to practice at the time of care
• I am responsible for accurately reporting my child’s location
• The provider may recommend in-person care when appropriate
• This program does not provide emergency care
I understand that in an emergency, I will call 911 or seek immediate medical attention.
IX. PHARMACY AND SHIPPING DISCLOSURE
I understand that prescriptions may be filled by a licensed third-party pharmacy and shipped directly to my home.
I understand that:
• The practice does not control pharmacy operations or shipping carriers
• Delivery timing cannot be guaranteed
• Medication may require temperature-controlled handling
• I am responsible for proper storage upon receipt
• The practice is not responsible for delays, damage, or loss of the medication
• Replacement of lost, stolen or improperly stored medication may not be available
X. CASH-PAY AND FINANCIAL RESPONSIBILITY
I understand that this program operates exclusively on a cash-pay basis. The practice will not bill any insurance carrier or health plan for services provided under this program.
I understand that:
• Insurance may not be billed
• I am responsible for all costs, including visits, labs, medications, and shipping
• Fees and pricing may change
• Refunds are not available once services have been rendered or medication has been dispensed, except as required by applicable law.
XI. OFF-LABEL USE
I understand that some aspects of treatment (such as dosing, duration, or clinical use) may differ from FDA labeling. This is known as “off-label” use and is based on medical judgment and available evidence.
XII. ALTERNATIVES
I understand that alternatives include:
• Lifestyle and behavioral treatment alone
• Structured pediatric weight management programs
• Other medications
• Bariatric surgery evaluation (when appropriate)
• No treatment
XIII. VOLUNTARY PARTICIPATION AND DISCONTINUATION
I understand that:
• Participation is voluntary
• Treatment may be stopped at any time
• The provider may discontinue treatment if it is no longer medically appropriate or if safety, compliance, or legal concerns arise
XIV. PARENT / GUARDIAN CONSENT
XV. PATIENT ASSENT (Ages 12-17)
This section is for you, the patient. You do not have to participate, and you can stop treatment at any time without getting in trouble.
I understand the information provided about this treatment, including what the medication does, the possible side effects, and that I can stop treatment at any time. I had the opportunity to ask questions and agree to participate in this treatment.
(Signature) Type full name to sign: ______________________________________
Date: ______________________________________
EMERGENCY CONTACTS
• Emergency: 911
• Suicide & Crisis Lifeline: 988
• Crisis Text Line: Text HOME to 741741
• Practice Contact: ____________________________
