Consent for the 3-Month Weight Loss Program
Clinically supervised tirzepatide (Mounjaro®) injection under the supervision of Dr. Rajat Goel. This takes about 5 minutes.
About your program
What's included
- Prescription weight loss injection, given only after medical evaluation, at the dose your doctor decides
- Our prescription must not be used to buy or purchase the KwikPen from outside.
- Expert dietitian support with a personal diet plan
- Weekly online group meeting with the doctor
- Dose escalation and safety monitoring
- Lifestyle and exercise guidance
Pen needlesAlcohol swabsGel ice packHindivine pouchWhey protein (5 sachets)
About the medicine
- Tirzepatide is a once-weekly injection under the skin (belly, thigh or upper arm). It reduces appetite, slows stomach emptying and helps control blood sugar.
- It is a prescription medicine. The dose starts low and is increased only by your doctor. Never change, skip or double a dose on your own.
- Do not stop the injection / KwikPen without consulting your doctor, to prevent weight regain.
- It works best with a calorie-controlled diet, enough protein and water, and regular activity.
- Results differ from person to person. Weight may come back after stopping if lifestyle changes are not kept up.
Medical history
Please answer honestly. Hiding information can put your health at serious risk.
Doctor review needed. Based on your answers, the doctor must check whether this medicine is safe for you before it is given. You can still submit this form.
Side effects & risks
Tap each item to read it.
Common side effects
Nausea, vomiting, diarrhoea, constipation, stomach pain, bloating, indigestion, less appetite, tiredness, and redness or itching where you inject. These are usually mild and more common when starting or increasing the dose. Hair thinning and muscle loss can happen with fast weight loss, so eat enough protein and exercise.
Thyroid tumours
Tirzepatide caused thyroid C-cell tumours in rats. It is not known if this happens in humans. Report a neck lump, trouble swallowing, breathlessness or lasting hoarseness.
Pancreatitis
Severe stomach pain that does not go away and may spread to the back, with or without vomiting. Stop the injection and call the doctor right away.
Low blood sugar
More likely if you take insulin or sulfonylurea tablets. Signs: sweating, shaking, dizziness, confusion, fast heartbeat.
Serious allergic reaction
Swelling of face, lips, tongue or throat, trouble breathing, or severe rash. Go to emergency care immediately.
Kidney problems
Dehydration from vomiting or diarrhoea can harm the kidneys. Drink enough fluids.
Gallbladder problems
Gallstones or inflammation, especially with fast weight loss. Signs: pain in the upper right belly, fever, yellow eyes or skin.
Stomach, eye and mood changes
Severe stomach or bowel problems can occur. In people with diabetes, diabetic eye disease may worsen. Report any new or worse depression, thoughts of self-harm, or unusual mood changes to the doctor at once.
NAION (non-arteritic anterior ischemic optic neuropathy)
A rare condition in which reduced blood flow to the optic nerve causes sudden, usually painless loss or blurring of vision in one eye. It has been reported with GLP-1 medicines. If this happens, stop the injection and get urgent eye care, then inform the doctor.
Surgery or anaesthesia
The medicine slows stomach emptying. Tell any surgeon or anaesthetist that you take tirzepatide before any procedure.
Safety, medicines & storage
Pregnancy & contraception
- Do not use this medicine during pregnancy. Tell the doctor at once if you become pregnant.
- If you are planning a pregnancy, stop the KwikPen 6 weeks before the planned pregnancy.
- Birth-control pills may work less well. Switch to a non-oral method, or add a barrier contraceptive, for 4 weeks after starting and 4 weeks after every dose increase.
Other medicines
- The absorption of tablets you take may change. Medicines like warfarin need closer checks.
- Insulin or sulfonylurea doses may need to be lowered by your doctor.
- Tell the doctor before starting any new medicine.
Storing your KwikPen
- Keep unused pens in the fridge at 2°C to 8°C. Never freeze. Throw away a pen that has frozen.
- After first use, a pen can stay at room temperature up to 30°C for up to 30 days, away from heat and light.
- Never share pens or needles. Put used needles in a sharps container.
- Keep everything out of reach of children.
Your responsibilities
- I will follow the dose schedule, diet plan and exercise advice, and attend the weekly online doctor meetings.
- I will do any blood tests the doctor advises.
- I will report side effects on +91 8889995465. In an emergency I will go to the nearest hospital.
- Results are not guaranteed and depend on my body and how well I follow the plan.
- The doctor may lower, pause or stop the medicine if it is not safe for me.
- Medicines once given cannot be returned. Refunds, if any, follow Hindivine's written clinic policy.
- I will keep other members' details private in group meetings. My medical details stay confidential with Hindivine.
- I will not sell, share or give the medicine to anyone else.
Optional (you can say no)
Declaration & signature
I have read this form, or it was explained to me in a language I understand. The purpose, benefits, risks, side effects and alternatives (diet and exercise alone, other medicines, or bariatric surgery) were explained. My questions were answered. I voluntarily agree to join the Hindivine 3-Month Weight Loss Program and to receive tirzepatide under doctor supervision. I know I can withdraw at any time.
Sign here with your finger
✓
Consent submitted
Thank you. Our medical team will review your form before your first dose.
Questions? Call +91 8889995465 · www.drrajatgoel.com