Semaglutide & GLP-1 Consent Form Template for Med Spas

Not medical or legal advice. This page describes how GLP-1 consent forms are commonly structured and what they usually need to address. It does not set clinical standards, recommend any medication or dose, or state the law of any state. Every consent form must be approved by the prescriber and your practice's medical director and reviewed by a healthcare attorney before a patient signs it.

Weight-loss medication is unlike almost everything else on a med spa menu. A filler appointment or a laser session is a single event with a defined end. A semaglutide or tirzepatide program is ongoing prescription therapy: the patient takes a drug for months, often at home, with effects that build gradually and side effects that can arrive at any point along the way. Its consent form has to describe an ongoing relationship between patient and prescriber, not a single visit.

This guide is about one document: the patient consent form for semaglutide, tirzepatide and related GLP-1 therapy. The wider regulatory picture, from prescribing authority to sourcing and enforcement, lives in our GLP-1 med spa compliance guide, which keeps a summary of the consent elements; this page sets out the full document.

We do not give doses, titration schedules, units, storage temperatures or timelines here, and we do not tell a prescriber whom to treat. Those belong in your clinical protocols, signed by your medical director and checked against each product's current labeling.

Is Informed Consent the Same as a Signed Semaglutide Consent Form?

No. Informed consent is the discussion in which a qualified prescriber explains the proposed medication, the alternatives and the risks, answers the patient's questions, and the patient agrees to go ahead. The signed form is the evidence of that discussion. A beautifully drafted form does not create consent that was never obtained, and a genuine conversation with no signed record is very hard to prove later.

With GLP-1 therapy the gap between the two is wider than usual, because so much of the risk sits outside the clinic. What the patient understood on day one determines whether they recognize a warning sign at home, report a new prescription, and keep the follow-up appointments the program depends on. A form signed at the front desk in a hurry, before the patient has met the prescriber, records very little of that.

The prescriber's evaluation comes before the form

Consent to a prescription medication only makes sense once a licensed prescriber has decided the patient is a candidate. That decision rests on a good-faith examination: history, measurements, a medication review, a contraindication screen, and whatever baseline testing your protocol requires. The consent form should be completed after that evaluation and should refer to it, not stand in for it. If the form is signed first and the evaluation happens later, or the "evaluation" is a questionnaire nobody with prescriptive authority reviewed, the sequence itself becomes a finding. Our guide to good-faith exam requirements by state explains what that examination involves and where telehealth fits.

The practical rule is simple. The chart should show the evaluation, the prescriber's decision, the consent discussion and the signed form, in that order. Our GLP-1 patient screening and eligibility guide sets out what the screening record should contain.

What the signed form actually proves

A good GLP-1 form proves that this patient, on this date, was told about this specific medication, in this formulation, with these risks and these monitoring commitments, and agreed to proceed. Each part can fail independently. A form that says "weight-loss injection" without naming the drug cannot show the patient knew what they were taking. A form that describes a branded product when the patient received a compounded one misstates the very fact the patient most needed. A form with no monitoring section cannot show the patient accepted any obligations at all. And a form signed after the first dose was dispensed proves nothing about consent.

Who Should Obtain Consent for GLP-1 Therapy?

The prescriber who evaluated the patient and decided to prescribe should lead the consent discussion. That might be a physician, or a nurse practitioner or physician assistant acting within the prescriptive authority and collaboration or supervision arrangements their state requires. Staff can hand over the form and reinforce education, but the risk conversation belongs to the person accountable for the prescription.

Many med spas split the work: a prescriber evaluates and prescribes, and a registered nurse later administers in-clinic doses or teaches self-injection. The form should be honest about that. Give the prescriber a signature line for the consent discussion, and record separately who taught self-injection or administered doses. Who may prescribe, delegate and administer differs by state; our regulations by state hub covers supervision and delegation, and our telehealth prescribing guide covers remote evaluations.

What Must a Semaglutide Consent Form Include?

A semaglutide consent form must name the medication and say whether it is an FDA-approved brand or a compounded preparation, explain how it is supplied and used, describe expected effects in general terms, list alternatives, common side effects and serious risks, record the prescriber's screening questions, set monitoring commitments, warning signs, storage, cost and signatures.

Use the list below as a checklist against your current form. Each element is explained in turn afterwards.

1. The medication and its source — the specific product prescribed, and whether it is an FDA-approved branded product or a compounded preparation, stated as a disclosure of fact.
2. Indication and on-label or off-label use — what the product is approved for, and whether this patient's use falls inside or outside that approval.
3. How it is supplied and used — the dosage form, whether doses are given in clinic or self-administered at home, and confirmation that injection teaching was provided where applicable.
4. Expected effects — what the medication is intended to do, in general terms, with no promised amount of weight loss or timeline.
5. Alternatives — lifestyle programs, other medications, referral for other options, and not starting treatment.
6. Common side effects — the expected, usually manageable effects, especially gastrointestinal ones, listed apart from serious risks.
7. Serious risks — the risks named in the product labeling and in your protocol, each on its own line, including the boxed warning.
8. Screening questions — confirmation that the prescriber asked about personal and family history relevant to the labeling warnings, pregnancy and breastfeeding, and other medications.
9. Follow-up and monitoring — the visits and checks the practice commits to, and the patient's obligation to attend them.
10. When to seek care — the symptoms that need an immediate call or emergency care, and how to reach the practice after hours.
11. Storage and disposal — confirmation that the patient received instructions for storing the medication and disposing of needles and pens safely.
12. Financial terms — the price, what a refill requires, and what happens if the patient misses monitoring or stops.
13. Signatures and date — patient attestation and signature, prescriber name, credentials and signature, date, and the form's version.

The medication, and whether it is FDA-approved brand or compounded

Name the product, not the class. "Semaglutide" alone is not enough when the practice could be prescribing a branded injectable, a branded oral tablet or a compounded preparation, each with different labeling and a different regulatory status. The form should record the product the prescriber chose, and leave room to note a change if the pharmacy dispenses something different.

The second half of this element is the one most often missing: a clear statement of whether the medication is an FDA-approved branded product, such as Wegovy, Ozempic, Mounjaro or Zepbound, or a compounded preparation. Treat this as a disclosure of fact, not a legal opinion about the product. The form does not need to explain compounding law; it needs to tell the patient which kind of medication they are getting. If it is compounded, the form should say that the compounded version is not FDA-approved and is not manufactured under the same oversight as the commercial product. The section on compounded products below covers what else changes.

Indication and on-label or off-label use

Patients are entitled to know when a medication is being used for something other than its approved purpose. The classic example in this category is prescribing Ozempic, which is approved for type 2 diabetes, for weight loss in a patient without diabetes. That is lawful off-label prescribing, but it should be disclosed on the form and supported by a clinical rationale in the chart. Where the goal is weight management, Wegovy and Zepbound are the products approved for it, and a form for either can say so directly.

Keep the language plain: "This medication is approved by the FDA for [indication]. Your prescriber is recommending it for [purpose], which is [within / outside] that approval." A patient who reads that sentence and signs beneath it cannot easily argue later that the off-label status was hidden.

How it is supplied and self-administered

Most GLP-1 patients give themselves the medication at home, at least after the first visits. The form should say which model applies: doses given in the clinic, self-administration at home after teaching, or a mix. Where the patient self-injects, the form should confirm that they received hands-on instruction from a qualified clinician, were shown how to use the specific device or vial they will be using, demonstrated the technique back, and received written instructions to take home.

The form should not reproduce the injection technique or the dosing plan. Those change with the product and the prescriber's decisions and belong on a separate instruction sheet or in the prescription itself. What the form needs is the patient's acknowledgement that they were taught, will follow the prescribed plan without adjusting doses themselves, and will call the practice if unsure. Our GLP-1 injection protocol guide covers the clinical side, and our oral GLP-1 guide covers the tablet products.

Expected effects, in general terms

Describe what the medication is intended to do: reduce appetite and help the patient lose weight gradually alongside changes in diet and activity. Say that results vary between people, that some patients lose less than they hoped, and that the practice cannot guarantee any particular outcome. Do not print an expected percentage of weight loss or a timeframe; a number on a consent form reads as a promise.

Two expectations deserve their own sentence. First, weight loss on these medications includes some loss of lean mass as well as fat, which is why protein intake and resistance exercise are part of a sound program; our GLP-1 muscle loss guide explains the clinical side. Second, appetite and, for most people, a substantial share of the weight lost tend to return after the medication is stopped. Patients who hear that at the start make better decisions and file fewer complaints than patients who discover it later.

Alternatives

Informed consent requires that the patient knew there were other options. For GLP-1 therapy those usually include a structured lifestyle program without medication, other weight-management medications, referral to primary care, endocrinology or a surgical evaluation where appropriate, and simply not starting treatment. If the practice offers both branded and compounded options, the choice between them is itself an alternative the form should record. The form only has to show that alternatives were discussed.

Common side effects

List the expected effects so the patient recognizes them as known and manageable: nausea, vomiting, diarrhea, constipation, fatigue, and reactions at the injection site for injectable products. Say that these are common, that they often ease as the body adjusts, and that the patient should contact the practice if they are severe, persistent, or stop the patient eating or drinking normally. Avoid attaching a timeline or a frequency. You rarely have a sourced figure that applies to your exact product and population, and a wrong one undermines the rest of the form.

Serious risks to disclose

Each serious risk should sit on its own line, in plain language, with a short explanation of what it means for the patient. Build the list from the current labeling for the specific product you prescribe and from your medical director's protocol. For the GLP-1 medications used in weight management, our pages consistently treat the following as items the form should address:

• Thyroid C-cell tumors (boxed warning). The product labeling carries a boxed warning about thyroid C-cell tumors, and a personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2 is a contraindication. The form should name the warning in words a patient can follow and confirm that the history question was asked.
• Pancreatitis. Inflammation of the pancreas, which can be serious. The patient should know that severe abdominal pain, with or without vomiting, needs prompt attention.
• Gallbladder disease. Including gallstones, which rapid weight loss of any cause can make more likely.
• Low blood sugar with certain medications. The risk rises when a GLP-1 is combined with insulin or a sulfonylurea, which is why those medications must be disclosed and coordinated with whoever prescribes them.
• Dehydration and kidney effects. Vomiting and diarrhea can lead to dehydration, which in patients with limited kidney reserve can cause kidney injury.
• Serious allergic reactions. Including, rarely, reactions that need emergency care.
• Anesthesia and procedures. These medications slow stomach emptying, which matters before sedation or surgery. The patient should agree to tell any surgeon or anesthesiologist that they are taking one.

Your medical director may add others drawn from the labeling, such as considerations for patients with diabetic eye disease or gastrointestinal motility disorders. Do not soften the list with words like "extremely rare"; you have no reliable figure to back that up, and reassurance weakens the disclosure.

Screening questions, framed for the prescriber

The consent form is not the screening tool, but it should confirm that screening happened. Frame these items as questions the prescriber asked and the patient answered truthfully, not as clinical rules printed for the patient to apply to themselves. Whether a given answer rules a patient out is the prescriber's decision, made in the chart, under your protocol. The form should record that the patient was asked about, and answered:

• Personal and family history relevant to the labeling warnings, including thyroid cancer of the medullary type and multiple endocrine neoplasia, asked in those words rather than as "any thyroid problems?"
• History of pancreatitis, gallbladder disease, kidney or liver problems, and gastrointestinal conditions.
• Diabetes, and diabetic eye disease where relevant.
• Pregnancy, plans to become pregnant, breastfeeding, and contraception in use.
• All other medications and supplements, including insulin, sulfonylureas, oral medications whose absorption timing matters, and any weight-loss products obtained elsewhere.
• Allergies, including to any previous GLP-1 product.

Follow those items with an attestation that the information is complete and accurate, and a commitment to tell the practice promptly about changes: a new diagnosis, a new prescription from another clinician, or a pregnancy. The pregnancy point deserves its own line. The form should record that pregnancy risk and contraception were discussed and that the patient understands the practice's policy on stopping the medication before a planned pregnancy and on what to do if pregnancy occurs.

Follow-up and monitoring commitments

A GLP-1 consent is a two-way agreement. The practice commits to follow-up: reassessment visits, tolerability checks, weight and measurements, and any repeat laboratory work your protocol requires before dose changes or refills. The patient commits to attend those visits, report side effects honestly, and not obtain the same class of medication elsewhere while under the practice's care. The form should describe this structure and refer to the patient's written monitoring schedule rather than printing specific intervals, which change as protocols are updated.

State what happens if the patient misses monitoring. A program that keeps refilling prescriptions for patients who never return is a documented failure of oversight, and the form is the right place to say, in advance, that refills depend on follow-up. Our GLP-1 monitoring schedule template explains how to build the schedule the form refers to.

When to seek care

Warning signs belong on the consent form itself, not only on a handout, because they are part of the risk disclosure. Drawing on the risks above, the patient should be told to contact the practice promptly for severe or persistent abdominal pain, repeated vomiting or an inability to keep fluids down, signs of dehydration, symptoms of gallbladder problems as described on their instruction sheet, a lump or swelling in the neck, persistent hoarseness, and symptoms of low blood sugar in patients on other glucose-lowering medication. Facial or throat swelling, difficulty breathing or other signs of a severe allergic reaction need emergency services, not a call back.

Give a contact route that works outside business hours, or a clear instruction on what to do when the practice is closed. A daytime line that goes to voicemail is not an emergency contact for a patient who is vomiting at midnight.

Storage and disposal of supplies

For self-administered products, the form should confirm that the patient received written instructions on storing the medication according to its labeling and the dispensing pharmacy's directions, on not using medication that has been stored improperly or has expired, and on disposing of needles and used pens safely in a puncture-resistant sharps container rather than loose in household trash. It should also say what to do with unused medication if treatment stops. Do not print storage temperatures or in-use periods on the form; they differ between products and are best taken from the labeling and the pharmacy label on the box. The acknowledgement is what matters: that the patient was told, in writing, and agreed to follow the instructions.

Financial terms

Cost disputes in cash-pay programs often end up framed as consent problems. The form, or a financial agreement it references, should state the price structure, what is included, what a refill requires, such as a follow-up visit, a tolerability check and any repeat labs, the refund position for patients who are found ineligible or stop early, and an explicit statement that no particular result is guaranteed. If pricing differs between branded and compounded options, the form should not leave any doubt about which one the patient is paying for.

Signatures, date and attestation

The patient signs and dates the form before the first dose is dispensed or administered. The prescriber who performed the evaluation and held the discussion prints their name and credentials and signs to confirm it. Where a nurse provided injection teaching, a separate line can record that. Include a first-person attestation above the patient's signature: that they read the form, had the opportunity to ask questions, had them answered, understand that results are not guaranteed, and agree to proceed. Record the form's version number so you can show later exactly what text the patient saw.

Does a Compounded GLP-1 Need a Different Consent Form?

Yes. A compounded semaglutide or tirzepatide preparation needs its own compounding-specific consent, or a clearly separate section, stating that the product is not FDA-approved, explaining its known risks, and recording the patient-specific clinical reason it was prescribed instead of the approved product. A branded-product form used for a compounded preparation misdescribes what the patient received.

This matters because of where compounding now stands. With semaglutide and tirzepatide off the FDA shortage list, routine compounding of copies of the branded products is no longer permitted. Our compounded GLP-1 503A vs 503B guide explains the narrow route that remains: a 503A pharmacy compounding for an individual patient, on a patient-specific prescription, where the prescriber has documented a clinical need the approved product cannot meet, such as a verified allergy to an inactive ingredient or a dose strength the approved products do not offer. Whether a preparation is lawful is a question for the prescriber, the pharmacy and counsel; the form's job is to tell the patient the truth about the product.

In practice, a compounded consent adds four things to the core form. It states that the preparation is compounded and is not an FDA-approved product. It explains, in terms the patient can follow, that it is not made under the same oversight as the commercial product and that the known risks of the approved medication still apply. It records the clinical reason the prescriber chose a compounded preparation for this patient, matching the individualized rationale in the chart rather than a phrase pasted onto every patient's form. And it identifies the dispensing pharmacy, with the lot number recorded in the chart for traceability.

Is There a Free Semaglutide Consent Form PDF?

Free semaglutide consent PDFs exist, but treat one only as a starting point. It must be rewritten to match the actual product and its source, your prescriber's evaluation and monitoring process, and your state's consent requirements, then approved by your medical director and reviewed by counsel before any patient signs it.

A generic download cannot know whether you prescribe branded or compounded product, injectable or oral, or how your follow-up and refill rules work.

When you evaluate any template, free or paid, check it against the element list above. Look specifically for a product field rather than a generic "weight-loss injection" label, a branded-or-compounded disclosure, an off-label statement, the boxed warning named in plain words, screening questions framed as the prescriber's, a monitoring commitment, warning signs with an after-hours contact, storage and sharps instructions, and separate prescriber and patient signature lines. Then adapt it: replace every generic term with your products and process, align the risk language with current labeling and your protocol, and add a version number and approval date.

Does Tirzepatide Need a Separate Consent Form?

Not necessarily. Where tirzepatide differs from semaglutide only by product name, one well-built GLP-1 form can serve both, provided it has a product field that is completed for every patient and does not list every drug on your menu with none selected. The structure is the same: product and source, indication and off-label status, how it is supplied, expected effects, alternatives, common and serious risks, screening, monitoring, warning signs, storage, cost and signatures.

The differences that do matter are product-specific details the form should take from the labeling for the drug actually prescribed. Tirzepatide is a dual GIP/GLP-1 receptor agonist, so a mechanism sentence written for semaglutide will not be accurate for it. The approved branded products are Mounjaro and Zepbound rather than Ozempic and Wegovy, and the indication and off-label statement must match whichever one is used. Any differences in labeled warnings, interactions or patient instructions between the products should be reflected in a product-specific section rather than smoothed over. Our tirzepatide protocol guide covers the clinical protocol.

How Should the Form Handle Stopping Treatment?

Every GLP-1 consent should address the end of treatment as well as the start. Patients who stop often regain a substantial share of the weight they lost because the drug's appetite effects fade once it clears, and a program that never mentioned this invites the complaint that the patient was sold a cure. The form should say so plainly, explain that continuing, tapering and stopping are decisions to make with the prescriber, and state that the practice will document a plan when treatment changes.

The form should also record the criteria under which the prescriber may pause or stop the medication: intolerable side effects, a new contraindication such as pregnancy, missed monitoring, inadequate response, or reaching the agreed goal. Our GLP-1 maintenance and off-ramping guide covers the clinical and charting side of that transition.

What Should a Semaglutide Consent Form Template Look Like?

A usable template reads in a logical order for the patient and lets a reviewer find each required element quickly. The outline below is a common structure. It is a layout, not wording to copy; your prescriber, medical director and counsel supply the final text.

How Should You Document and Retain GLP-1 Consent?

The consent form is only as strong as its connection to the rest of the chart. A signed form that cannot be matched to a specific evaluation, prescription and product is much weaker than a modest form inside a complete, consistent record.

Linking the form to the chart

For each patient, the chart should show the good-faith evaluation, the screening record, the prescriber's clinical rationale, the signed consent, the prescription, the dispensing pharmacy, the product and lot number where the practice handles the medication, any in-clinic administrations, the teaching record for self-administration, and each follow-up visit. The product and source on the consent should match the prescription. Where they differ, the chart should show why and that the patient agreed before the change took effect. Our intake form template guide covers the history the consent relies on.

How long to keep signed GLP-1 consent forms

Signed consent forms are part of the medical record and follow the same retention rules as the rest of the chart. Those rules come from state law and payer or other requirements that vary, so there is nothing specific to GLP-1 forms to add. Our medical records retention guide covers retention periods and storage. Keep superseded versions of the template too, with a log of when each version went into use, who approved it and what changed.

Electronic consent

Many weight-loss programs collect consent through a patient portal, particularly where the evaluation happens by telehealth. Electronic signature is widely used, but the platform must be able to show who signed, which version of the form they saw, and when. It should preserve the exact text the patient agreed to. Confirm with counsel that your platform and process meet the requirements in each state where you treat patients.

When do you need a new GLP-1 consent?

Re-consent whenever something material changes. For GLP-1 therapy the common triggers are:

• A change of product, such as semaglutide to tirzepatide, or one branded product to another with a different indication.
• A change of source, especially a move between branded and compounded product, or to a different compounding pharmacy.
• A change of route or form, such as injectable to oral.
• A material change to the treatment plan, such as moving from active weight loss to a maintenance plan, restarting after a long pause, or a change in the agreed dose plan that your protocol treats as material.
• A change in the patient's health: pregnancy or plans for it, a new diagnosis relevant to the risks above, or new medications such as insulin or a sulfonylurea.
• A serious side effect, which should prompt a fresh discussion before treatment continues.
• A new version of your form, so that continuing patients sign the current wording.
• A new prescriber taking over the patient's care.

Routine dose adjustments within a plan the patient has already consented to do not usually need a new form, but each should be documented in the chart with the prescriber's reasoning.

What GLP-1 Consent Form Mistakes Show Up in Chart Reviews?

When a board, an insurer or a lawyer reviews a weight-loss chart, the consent form is among the first documents requested. The same weaknesses recur.

A general aesthetic consent used for a prescription drug

A one-page "treatment consent" covering everything from facials to injections says nothing useful about a medication taken for months. GLP-1 therapy needs a distinct document.

The product or its source is never stated

"Weight-loss injection" or "semaglutide program" leaves open the single most important fact: what the patient actually received and whether it was approved. Name the product and the source every time.

A branded form for a compounded preparation

This is the most damaging version of the problem above, because the form affirmatively describes something the patient did not get. If the practice uses both, it needs both forms or a compounded section that is impossible to skip.

The boxed warning buried or paraphrased away

"Thyroid issues" in a long list of side effects is a disclosure in name only. Name the warning and the history question plainly.

No monitoring commitment

A form that never mentions follow-up gives the practice no basis for withholding refills and gives the patient no notice that monitoring is part of the deal.

No warning signs, no after-hours contact

When a patient with severe abdominal pain waited because they did not know it mattered, or could not reach anyone, the missing warning section becomes part of the complaint.

How Does GLP-1 Consent Differ From Procedure Consent?

Procedure consents, such as those for filler, peels or lasers, describe a single treatment and its aftermath. GLP-1 consent describes ongoing therapy with a prescription drug, much of it taken at home, with obligations on both sides that continue for as long as treatment lasts. The closest relative on a typical menu is IV therapy, which also involves medications and screening; our IV therapy consent form template shows how the same structure applies there. The baseline rules that apply to every consent in your practice, from capacity to minors to photo releases, are set out in our med spa consent forms guide.

Key Takeaways

• Informed consent is the prescriber's discussion; the signed form is the proof. The good-faith evaluation comes first.
• Name the product and state whether it is an FDA-approved brand or a compounded preparation, as a disclosure of fact.
• Separate common gastrointestinal effects from serious risks, and name the boxed warning plainly.
• Make monitoring a two-way commitment, and say that refills depend on it.
• Use a compounding-specific consent for any compounded preparation.
• Re-consent on a change of product, source, route or treatment plan; keep version history; follow your records-retention rules.
• A template is a starting point; the prescriber and medical director approve it and counsel reviews it.

This guide is general information about how semaglutide and GLP-1 consent forms are structured and maintained. It is not medical or legal advice, does not set clinical standards, does not recommend any medication or dose, and does not state the law of any state. Every consent form must be approved by the prescriber and your practice's medical director and reviewed by a healthcare attorney licensed in your state before use, and risk disclosures should be checked against each product's current labeling.