Templates / Semaglutide consent form: Free template with label-dated risks and a compounded section

Templates

Semaglutide consent form: Free template with label-dated risks and a compounded section

Free PDF • 7 pages, print-ready • Clinician-reviewed

Maja Popovska Last updated November 13, 2026 Reviewed by Dr. Vanja Kitanova

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This semaglutide consent form is a free template for US practices, built from the FDA prescribing information for semaglutide revised in June 2026. The form covers the label contraindications, the boxed warning, every current warning and precaution, a compounded-product section, dose-step check-ins, and patient and prescriber signatures.

Every risk line carries its label section number and revision date, so you can see when the form has fallen behind the label. We call that label-dated consent. Review it with your medical director and legal counsel before use.

Template details

Template type

Consent form

Format

Printable PDF, 7 pages

Sections

2 sections

Fields to complete

24 fields

Best for

Templates

Key takeaways

Keep the label’s two contraindications separate from the exclusion criteria your medical director adds.

The Wegovy label revised in June 2026 has eleven warnings and precautions, including heart rate, aspiration under sedation and never sharing a pen.

The suicidal behavior and ideation warning left the Wegovy label in February 2026, so a form that still lists it is out of date.

Compounded semaglutide needs its own section: Not FDA approved, no salt forms, the dose in mg and mL, and a 28-day vial discard date.

Book a dose-step check-in before each label dose increase, at weeks 4, 8, 12 and 16, and again at maintenance.

What’s in this semaglutide consent form?

This semaglutide consent form has 16 sections, from patient details and label contraindications to a compounded-product disclosure, dose-step check-ins, financial terms and signatures. Each risk statement comes from the Wegovy prescribing information on DailyMed, revised 06/2026, with its section number printed beside it.

When we reviewed five published semaglutide consent forms in November 2026, none had a prescriber signature line. Four listed contraindications the label doesn’t, and one still carried the removed suicidal ideation warning. The table shows where each section of this form gets its wording.

Have your medical director and legal counsel review the form before the first patient signs it. If you also need a separate history form, start from our weight loss intake form.

Which risks does the form take from the FDA label?

The form takes the boxed warning, the two contraindications and all eleven warnings and precautions from the semaglutide injection label revised in June 2026. Each one keeps its section number.

The source is the Wegovy prescribing information, which DailyMed shows as revised 06/2026. Compounded semaglutide is not FDA approved, so it has no FDA-reviewed label of its own. The form therefore uses the approved product’s label as the risk reference for every patient.

The eleven warnings and precautions, in label order:

1. 5.1 Thyroid C-cell tumors: The boxed warning, explained on the form in plain words.
2. 5.2 Acute pancreatitis: The label says to discontinue semaglutide if pancreatitis is suspected.
3. 5.3 Acute gallbladder disease: Gallstones and gallbladder inflammation have occurred in trials.
4. 5.4 Hypoglycemia: The risk rises with insulin or an insulin secretagogue such as a sulfonylurea.
5. 5.5 Acute kidney injury due to volume depletion: Most reported cases followed dehydration from nausea, vomiting or diarrhea.
6. 5.6 Severe gastrointestinal adverse reactions: The label doesn’t recommend semaglutide for patients with severe gastroparesis.
7. 5.7 Hypersensitivity reactions: Anaphylaxis and angioedema have been reported after approval.
8. 5.8 Diabetic retinopathy complications in patients with type 2 diabetes: Patients with a retinopathy history should be monitored.
9. 5.9 Heart rate increase: The label says to monitor heart rate at regular intervals.
10. 5.10 Pulmonary aspiration during general anesthesia or deep sedation: Patients tell providers before any planned procedure.
11. 5.11 Never share a Wegovy FlexTouch pen between patients, even if the needle is changed.

None of the five published practice forms we reviewed carries 5.9, 5.10 or 5.11. Two of them ask the patient to act outside your practice: Warning another provider before sedation, and never sharing a pen.

The label lists exactly two contraindications. One is a personal or family history of medullary thyroid carcinoma or MEN 2. The other is a prior serious hypersensitivity reaction to semaglutide or an excipient.

Pancreatitis history, type 1 diabetes and pregnancy are not on that list. The form keeps them for Section 5, where your medical director decides whether they exclude a patient.

Pregnancy has its own section. The label says semaglutide may cause fetal harm and advises stopping at least 2 months before a planned pregnancy, because of its long half-life.

Section 6.1 lists the reactions seen in 5% or more of patients, from nausea and diarrhea to hair loss. The adverse event lines on the form, Novo Nordisk at 1-833-934-6891 and FDA at 1-800-FDA-1088, are copied from the label.

The missed-dose rule differs by product. Wegovy’s label says to take a missed dose if the next one is more than 2 days away, and to skip it if less. The Ozempic prescribing information, revised 05/2026, allows a missed dose within 5 days instead.

Keep one consent form per drug, because each label carries its own risks, numbering and missed-dose rules. Mounjaro and Zepbound patients need a separate tirzepatide consent form for the same reason.

What changed on the semaglutide label in 2026

Two warnings changed on the Wegovy label in 2026: The suicidal behavior and ideation warning went in February, and a never-share-the-pen warning arrived in June. A form written before either date is out of step with the current label.

Label-dated consent is the fix. Every risk line on the form names its section and the label revision it was checked against. The “Label version checked” field records which revision the practice last compared the form with.

The label dates its 7.2 mg and tablet content only through dosage changes marked 08/2025, 12/2025 and 03/2026. So the form treats them as features of the current label rather than tying them to one month.

The decision rule is simple. Whenever the “Revised” date on the DailyMed label changes, compare sections 4 to 10 of the form against it. Then update the “Label version checked” field, even if nothing else moved.

What should a compounded semaglutide consent section say?

A compounded semaglutide consent section must say the product is not FDA approved or reviewed, name the pharmacy and concentration, and avoid brand names. It also records why this patient needs a compounded product.

FDA’s own wording sets the floor. Its page on concerns with unapproved GLP-1 drugs (content current as of 10/01/2026) says compounded drugs are not FDA approved. FDA does not review them for safety, effectiveness or quality before they are marketed. FDA adds that they should only be used when a patient’s needs cannot be met by an FDA-approved drug.

The shortage-era rules are over. According to FDA’s policy page for compounders (content current as of 04/01/2026), the dates run like this:

• February 21, 2025: FDA determined the semaglutide injection shortage was resolved.
• April 28, 2025: After the April 24 court ruling, FDA said enforcement discretion for 503A pharmacies had ended.
• May 22, 2025: The end of the period in which FDA said it would not act against 503B outsourcing facilities.
• As of the page’s 04/01/2026 update, FDA states that semaglutide does not appear on the 503B bulks list or the drug shortage list.

Under 503A, a compounded copy of an approved drug needs a prescriber to determine and document a significant difference for an identified individual patient. FDA has said it won’t act against a compounder filling four or fewer prescriptions of such a copy in a calendar month.

Adding vitamin B12 doesn’t help by itself: FDA may still treat semaglutide plus B12 as essentially a copy.

Those rules shape the compounded section of the form, which asks the prescriber for these fields:

• Product name: Exactly “compounded semaglutide”, never Ozempic or Wegovy. FDA has warned telehealth companies against calling a compounded drug a generic, or the same as an approved drug.
• Salt form check: Semaglutide base only. FDA says it is not aware of any lawful basis for compounding with semaglutide sodium or semaglutide acetate.
• Pharmacy: Its name, state and whether it is a 503A pharmacy or a 503B outsourcing facility.
• Concentration and dose: The concentration in mg per mL, and each dose written in mg and in mL, never in “units”.
• Prescriber’s reason: The documented clinical difference this patient needs.
• Vial dates: First use and a discard-by date 28 days later, even if medicine remains.

The mg and mL fields answer a documented problem. FDA’s dosing-error alert (content current as of 07/26/2024) describes patients drawing up five to 20 times the intended dose. Confusion between milliliters, milligrams and “units” may have contributed.

FDA’s page for telehealth companies promoting compounded drugs (content current as of 06/15/2026) is the source for the naming rule. FDA’s concerns page adds the 28-day vial guidance and a warning against using a vial that arrives warm. It also reports 990 adverse event reports for compounded semaglutide as of May 31, 2026.

The form contains no compounded or microdosing schedule. Dose steps on every version follow the prescriber’s order and the FDA label.

Which side-effect check-ins does the form set up?

The form sets up a dose-step check-in before each label dose increase, at the end of weeks 4, 8, 12 and 16, then at maintenance. The dates go in Section 12, so the patient signs up to them along with the risks.

The steps come from Table 1 of the Wegovy label. Patients take 0.25 mg in weeks 1 to 4 and 0.5 mg in weeks 5 to 8. They move to 1 mg in weeks 9 to 12 and 1.7 mg in weeks 13 to 16. Maintenance starts at week 17, at 1.7 mg or 2.4 mg for adult weight reduction.

Patients who tolerate 2.4 mg for at least 4 weeks may go up to a 7.2 mg maximum. The label also says to consider delaying escalation by 4 weeks if a dose isn’t tolerated. Each dose-step check-in is where that decision gets made and written down.

Every sign on the form’s stop-and-call list applies at every step. The table puts one beside each step so the conversation covers all of them by week 17. Each question is phrased from the label’s patient counseling section and Medication Guide, not from a practice protocol.

For Ozempic, the label’s steps differ. Patients start at 0.25 mg for 4 weeks, then take 0.5 mg. Each later increase, to 1 mg and then 2 mg, comes after at least 4 weeks. Book a check-in before each of those increases instead. To give Wegovy patients eating guidance between check-ins, hand out our Wegovy diet plan.

How do you take semaglutide informed consent with this form?

To take semaglutide informed consent, send this form before the visit, walk through each section with the prescriber, collect initials, then get both signatures.

1. Fill in the practice fields first: the label version checked, your exclusion criteria in Section 5 and your financial terms in Section 14.
2. Send the form before the appointment, so the patient reads it without a waiting room around them.
3. At the visit, the prescriber goes through Sections 4 to 13 and answers questions.
4. The prescriber ticks the product in Section 3 and completes Section 11 for a compounded product.
5. The patient initials each section, then the patient and prescriber sign and date Section 16.
6. Book the five dose-step check-ins from Section 12 before the patient leaves.

Where your state requires a medical director, that physician sets the Section 5 criteria. The prescriber’s signature confirms the conversation happened, which a patient-only signature cannot show.

A signed form doesn’t last for the whole course of treatment. Have the patient sign a new form when any of these happen:

• A switch between a branded product and compounded semaglutide, in either direction
• A new compounding pharmacy or a new concentration
• A label revision that changes Sections 4 to 10
• A restart after 2 or more missed doses in a row, which the label says means escalating again from a lower dose

How does the semaglutide consent form work in Pabau?

In Pabau, the weight loss clinic software we build, the consent form goes out before the visit as a digital form. The patient fills it in through the patient portal. Pabau GO, our iOS app for practitioners, takes care-pathway forms and consents in person instead.

The completed form lands in the patient record rather than sitting as a PDF in a shared drive. So the prescriber opening the chart at the week 8 check-in sees the signed consent next to the notes.

Practices can switch on the GLP-1 tab, which shows dose over time, the current dose, the licensed dose-step ladder and weight. The same tab carries weekly patient check-ins from the portal, so check-in answers sit beside the dose record.

The GLP-1 tab records the doses given, and the prescriber still decides each step. The flow from sending the form to the saved record looks like this.

When the practice stocks the medicine, each batch carries a batch number and expiry date in Pabau. The lot is then recorded against the patient and the appointment. For the rest of the clinical setup, see our comparison of the best EMR for weight loss clinics.

What can’t a paper or PDF consent form do?

A paper or PDF consent form records a signature, but it can’t file itself in the chart or collect side-effect answers between dose steps. Each limit maps to a way the practice records the same thing in Pabau.

Every Pabau plan includes the core features, and add-ons enhance the experience. If you want to see the consent form, the check-ins and the dose record working on one patient record, book a demo with our team.

Run semaglutide consent from the patient record

Send the semaglutide consent form before the visit and get it back signed in the patient record. With the GLP-1 tab switched on, weekly check-ins and doses sit on the same chart.

Book a demo

Conclusion

A semaglutide consent form is only as current as the label date on it. The label changed twice in 2026, and a form that still lists a removed warning tells a reviewer nobody checked it.

Branded and compounded semaglutide need separate disclosures, because FDA treats them differently and the dosing risks differ. The trade-off is a little upkeep: One label check whenever DailyMed shows a new revision, and a fresh signature when the product changes.

That upkeep is easier when the form, the check-ins and the dose record live on one chart. Book a demo to see how Pabau keeps semaglutide consent signed, dated and attached to every dose step.

Continue your research

Screening patients before the first dose? Ozempic questionnaire gives you a pre-treatment questionnaire to pair with the consent form.

Need an intake form for new weight loss patients? New patient weight loss intake form covers the history you collect before prescribing.

Checking a patient’s other medicines? GLP-1 medication list lists the GLP-1 drugs a patient may already be taking.

Teaching pen technique? Ozempic pen template helps patients track pen doses at home.

Setting up a weight loss service? How to start a weight loss clinic walks through licensing, staffing and setup.

Frequently asked questions