Mounjaro Refill

CURRENT PATIENTS OF WEST TEXAS OPTIMAL HEALTH ONLY.

Acknowledgment and Consent:

• I understand that Mounjaro (Tirzepatide) is a prescription medication used primarily for diabetes. I acknowledge that the use of this medication will be determined based on my medical history, current health status, and the discretion of the prescribing provider.
• I understand that I am paying for the fees of using an online Electronic Medical Records (EMR) system to send prescriptions, the time spent generating a progress note, and the cost of paying a supervising physician to oversee all prescriptions sent in.
• I understand that if a prior authorization is needed, approval may take longer than 1 week. This does not guarantee that the medication will be approved.
• I acknowledge that in the case that prior authorization is not granted, I will not be refunded the fee for the time spent completing the prior authorization.
• I acknowledge that West Texas Optimal Health does not accept insurance, and I am responsible for all costs associated with the medication and any follow-up visits or additional treatments.
• I understand that this request does not guarantee a prescription and that a thorough medical evaluation may be required. I consent to provide any necessary medical records and undergo any tests deemed necessary by the provider.
• I acknowledge that the benefits and risks of Mounjaro (Tirzepatide) will be explained to me during my consultation. I agree to follow the prescribed treatment plan and report any side effects or concerns to my provider promptly.
• I acknowledge that I am responsible for making sure the pharmacy I am requesting has the dose being requested.