Mounjaro: Information and Consent
If you are considering Mounjaro, please read this page before you book. Once you have read it, tick “I agree” on the booking screen. If anything is unclear, please ask the doctor during your consultation. This information also covers Rybelsus.
For patients under 18
Patients under 18 need consent from a parent or legal guardian. Your parent or guardian can come with you and fill in the consent form at the clinic. Alternatively, print the Guardian Consent Form below, have your parent or guardian sign it, and bring it with you.
1Information
[Medication / injection] Mounjaro / Rybelsus
About the medicine
Mounjaro (generic name: tirzepatide) is classed as a GLP-1 / GIP receptor agonist. It supports weight management by suppressing appetite and prolonging the feeling of fullness. You inject it under the skin yourself, once a week. Rybelsus (generic name: semaglutide) is classed as a GLP-1 receptor agonist and is taken by mouth. It supports weight management in the same way, by suppressing appetite. Take one tablet a day: as soon as you wake and on an empty stomach, with no more than half a glass of water (about 120 ml), swallowed whole without splitting or chewing, and eat, drink and take other medicines only after 30 minutes have passed.
Approval status
In Japan both medicines are approved as treatments for type 2 diabetes, but prescribing them for obesity or weight management is not approved (off-label use). I understand that, for this reason, in the unlikely event of a serious side effect, this would in principle not be covered by Japan’s Relief System for Sufferers from Adverse Drug Reactions or other public relief systems.
Common side effects
Nausea, vomiting, diarrhea, constipation, abdominal pain, reduced appetite and indigestion are relatively common. They tend to occur when starting treatment or increasing the dose, and usually ease with time. With Mounjaro, redness, swelling or pain at the injection site and dizziness may also occur.
Serious side effects
Hypoglycemia, acute pancreatitis and cholecystitis have rarely been reported. If you have severe abdominal pain, pain radiating to your back, repeated vomiting or a fever, stop using it immediately and seek medical attention.
Who cannot use it
It cannot be used by anyone who is pregnant, breastfeeding, or hoping to become pregnant. Please tell us if you have a history of pancreatitis, a serious gastrointestinal condition, are being treated for diabetes, or have a personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2. I understand that it cannot be prescribed if the doctor judges it unsuitable.
Storage and disposal
Store Mounjaro in a refrigerator at 2-8 degrees Celsius and do not allow it to freeze. Dispose of used injectors according to your local authority’s rules. Keep Rybelsus at room temperature and leave the tablets in their blister pack. Neither medicine may be passed to anyone else.
Other
Results vary from person to person and are not guaranteed. Severe dietary restriction is not required, but please aim for a balanced diet and moderate exercise, and keep alcohol to a minimum.
2Consent
Applies to every treatment
- I understand that results and how long they last differ from person to person, and that no outcome is guaranteed.
- I understand that more than one session may be needed to reach a satisfactory result.
- I understand that I may feel pain, pressure or bleeding during the procedure, and that pain is felt differently by different people.
- I understand that redness, swelling, heat, pain, itching and bruising can occur afterward, and usually settle within a few days to about two weeks.
- On the day of treatment I will avoid strenuous exercise, alcohol, saunas and long baths. I will not rub, press or massage the treated area.
- If a skin problem develops afterward, I will come in to be seen. I understand the consultation and any medication are charged separately.
- I understand that treatment cannot be given if I am pregnant or breastfeeding, if there is infection or inflammation at the site, if I am allergic to the product, if I have a serious systemic illness, or if the doctor judges it unsuitable for any other reason.
- I have declared my medical history, medication and allergies fully and truthfully. I understand the clinic cannot be held responsible for problems arising from anything I failed to declare.
- I understand that patients under 18 need the consent and signature of a legal guardian.
How long this consent lasts
- I understand that this consent remains valid for as long as I continue to receive the same treatment.
- I will tell you before treatment if my health, medical history, medication or the possibility of pregnancy changes.
3Agreement
I have received the explanation above, understood it, and consent to treatment.