Superpower Health

Informed Consent for Metformin

Last Updated and Effective:
12.8.2024

INTRODUCTION

THIS INFORMED CONSENT (THE"CONSENT") FOR METFORMIN SETS FORTH THE TERMS AND POLICIES FOR THE CLINICAL SERVICES PROVIDED BY SUPERPOWER MEDICAL GROUP OF CA PC, A CALIFORNIA PROFESSIONAL MEDICAL CORPORATION, AND OTHER THIRD-PARTY MEDICAL GROUPS (COLLECTIVELY,THE "MEDICAL GROUPS") THROUGH THE ONLINE TECHNOLOGY PLATFORM ("PLATFORM" OR "SUPERPOWER PLATFORM"), WHICH IS OWNED AND OPERATED BY SUPERPOWER HEALTH, INC. ("SUPERPOWER").

The purpose of this consent is to provide you with information about the risks, benefits, and safety considerations associated with taking metformin in order for you to make an informed decision as to whether or not to proceed with treatment, as well as to obtain your agreement to adhere to the treatment protocol as prescribed by your Medical Group healthcare provider (“Healthcare Provider”). Please read this form carefully and ask any questions you have before signing.

GENERAL INFORMATION

Metformin is an oral medication that is used to control blood sugar levels in people with type 2 diabetes, often in combination with diet and exercise.

Metformin may also be used for other conditions as determined by your healthcare provider.

How does metformin work (mechanism of action)?

Metformin works in a few different ways to help keep your blood glucose (sugar) from getting too high.

  • Metformin decreases the amount of glucose your body absorbs from things you eat and drink. 
  • Metformin reduces the amount of glucose that your liver makes. 
  • Metformin also helps your body’s own insulin to work better. (Insulin is a hormone that helps your body use glucose as a source of energy.) 

As with all therapies, there are potential benefits and risks.

Potential Benefits of Metformin:

  • May help lower blood sugar levels. 
  • Can promote weight loss. 
  • May have potential protective effects against cardiovascular complications.

Potential Side Effects of Metformin:

  • For all people: This medication may cause changes in your blood sugar. Thus, you should be aware of symptoms of both high and low blood sugar.
  • For all people: Causes reduction in absorption of B12; you will need to ensure proper supplementation of Vitamin B12.
  • Common: Nausea, vomiting, diarrhea, abdominal discomfort. 
  • Less common: Metallic taste, headache, dizziness.

Potential Serious Side Effects (Risks)of Metformin

  • ‍Lactic acidosis(build-up of lactic acid in the blood), which can be life-threatening, especially in individuals with kidney problems.
    • General ill feeling
    • Muscle pain
    • Difficulty breathing
    • Drowsiness 
    • Stomach pain ‍
  • Severe Allergic Reaction (anaphylaxis)
  • Low Blood Sugar (Hypoglycemia). When metformin is used with insulin or other medicines that lower your blood sugar by increasing your body’s own insulin levels, it can cause hypoglycemia (low blood sugar). The doses of the other medicines may need to be changed when taken with metformin. Call your healthcare provider right away if you have any of the following symptoms of low blood sugar.
    • Headache 
    • Crankiness or anxiety
    • Hunger
    • Dizziness or confusion
    • Blurry vision
    • Slurred speech
    • Sweating
    • Feeling jittery or shakiness
    • Fast heartbeat
    • Seizures
These are not all the possible side effects and risks of taking metformin.

Available Alternatives to Metformin:

There are often various options for treating the symptoms of poor metabolic health, obesity and high blood glucose levels as they develop including dietary supplements, and lifestyle modifications such as nutrition, physical exercise, and weight loss through other methods.

Contraindications:

You should not use Metformin if any of the following apply to you:

  • ‍Allergies to Ingredients. People who are allergic to any of the following should not take metformin: Metformin, Fortamet, Glumetza‍
  • Kidney Problems. Metformin should not be used if your kidneys are not working as well as they should be. If there is a concern about the health of your kidneys, your healthcare provider may do tests to determine if they are working well enough to take this medicine.‍
  • Metabolic Acidosis, Including Diabetic Ketoacidosis. Metformin should not be used in people with acute or chronic metabolic acidosis (when the chemical balance of acids and bases in your blood gets thrown off). Tell your healthcare provider if you have a history of metabolic acidosis or diabetic ketoacidosis.‍
  • You are pregnant or breastfeeding. It is unknown how metformin affects the fetus and if it is absorbed into the breastmilk.

Additional Important Safety Information Regarding Metformin:

  • Taking metformin with certain other medicines can cause adverse effects.Tell your doctor what other prescription and nonprescription medications, vitamins, nutritional supplements, and herbal products you are taking. Your doctor may need to change the doses of your medications or monitor you carefully for side effects. Talk to your healthcare provider before starting or stopping other medicines while taking metformin. You may need to monitor your blood sugar levels more closely during these times. In particular, make sure that you discuss if you are using any of the following before using metformin.
    • A carbonic anhydrase inhibitor, such as zonisamide (Zonegran), acetazolamide (Diamox), or methimazole
    • Medicines to treat diabetes, especially insulin or medicines that increase your insulin levels. Many other medicines can increase your blood sugar and can interfere with the effect of metformin.
  • Tell your doctor if you have or have ever had low levels of vitamin B12 in your body.
  • Tell your doctor if you drink alcohol of any kind often or in large amounts.
  • Inform your doctor about any existing medical conditions, especially kidney disease, liver disease, heart failure, or recent surgery. 
  • Do not take metformin if you are pregnant, breastfeeding, or planning to become pregnant without consulting your doctor. 
  • Take metformin exactly as prescribed, with meals to minimize stomach upset. 
  • Monitor your blood sugar levels regularly as directed by your doctor. 
  • Contact your doctor immediately if you experience symptoms of lactic acidosis, such as muscle pain, unusual tiredness, or rapid breathing
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TREATMENT PROTOCOL

Your Healthcare Provider will determine the appropriate dosage of metformin based on laboratory testing and medical history. Metformin dosing should be tailored to each patient based on individual lab values and guided by the prescriber’s clinical expertise. This approach ensures that treatment is both safe and effective, addressing the unique needs and physiological responses of each patient.

Once your dose is optimized, you will be placed on a maintenance dose.

In order to continue receiving prescriptions, you will be required to complete laboratory testing before initiating treatment, three months after starting treatment, and then annually thereafter, unless otherwise indicated by your clinician in the event of a dose change or the occurrence of side effects.

It is very important you follow your provider’s instructions.

USE OF TELEHEALTH

You understand that all ClinicalServices will be provided via telehealth. Telehealth involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare provider and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education, and may include, but is not limited to, one or more of the following:

  • electronic transmission of client medical records, photo images, personal health information or other data between a patient and a provider;
  • interactions between a patient and provider via audio, video and/or data communications (such as messaging or email communications);
  • use of output data from medical devices, sound and video files.
  • Alternative methods of care may be available to you, such as in-person services, and you may choose an alternative at any time.

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of customer identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

EXPECTED BENEFITS OF TELEHEALTH:  

  • Improved access to care by enabling a patient to remain at a remote site while consulting with practitioners at distant/other sites.
  • More efficient client evaluation and management.
  • Obtaining expertise of a distant specialist.

POSSIBLE RISKS OF TELEHEALTH

There are potential risks associated with the use of telehealth. These risks include, but may not be limited to:

  • There is the potential that conditions that could be diagnosed with an in-person visit may go undetected in a remote encounter especially because a full physical exam cannot be performed.
  • In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate decision making by your Healthcare Provider on the Superpower Platform;
  • Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment;
  • In very rare instances, security protocols could fail, causing a breach of privacy of personal health information;
  • In rare cases, a lack of access to complete health records may result in interactions or allergic reactions or other judgment errors.

Due to state licensure requirements of healthcare providers, you have to physically be in the state that your Medical Group Healthcare Provider is licensed in during your telehealth visit. By agreeing to this Consent, you are confirming that you will only opt in to care when you are in your state of residence or in one of our locations. Furthermore, you are confirming that your state of residence is one in which the Medical Groups are licensed to treat.

PLEASE NOTE: THE MEDICAL GROUPS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOUARE EXPERIENCING A MEDICAL EMERGENCY, ARE CONSIDERING HARMING YOURSELF OR OTHERS, OR ARE OTHERWISE IN IMMINENT DANGER, YOU SHOULD DIAL 9-1-1 AND/OR GO TOTHE NEAREST EMERGENCY ROOM.

You should seek emergency help or follow-up care when recommended by any healthcare provider or when otherwise needed. You should never discontinue medications or stop a course of treatment without first contacting your primary care provider or other medical professionals for advice. You should not delay treatment or advice from your primary care provider or other medical professionals based on information provided by the Medical Group Healthcare Providers via theSuperpower Platform.

All laws and protections for in-person medical care also apply to telehealth care. This includes confidentiality of information, access to medical records, and sharing of information that could identify you personally. You may decide that you do not want to use theClinical Services at any time, seek treatment elsewhere and/or with in-person offerings.  

INFORMED CONSENT & ADHERENCE TO TREATMENT PLAN

Please sign below to acknowledge your understanding and agreement of the following terms in order to proceed with treatment with Metformin with a Medical GroupHealthcare Provider via the Superpower Platform:

BY SIGNING THIS INFORMED CONSENT,YOU ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTAND THE INFORMATION PROVIDED ABOUT METFORMIN, INCLUDING THE RISKS, BENEFITS, AND SAFETY CONSIDERATIONS. YOU AGREE TO ADHERE TO THE TREATMENT PROTOCOL AS PRESCRIBED BY YOUR HEALTHCARE PROVIDER AND TO REPORT ANY SEVERE SIDE EFFECTS OR CONCERNS TO YOUR HEALTHCARE PROVIDER PROMPTLY.

Take your medication exactly as directed and written on your prescription label. By FDA law, this medication is not for resale, nor can it be returned for refund. Do not let anyone else take your medication. This medication is intended for use solely by the person for whom it is prescribed and should not be shared with any other individuals.Please follow the directions of your prescribing Healthcare Provider and on your prescription label carefully. If you need further explanation or have questions, please ask your prescribing Healthcare Provider to explain any part you do not understand.

You understand that the HealthcareProvider prescribing your metformin holds a professional license issued by the professional licensing board or agency in the state where they practice. You can report a complaint relating to the care provided by contacting the appropriate state professional licensing board.

NO GUARANTEES: You acknowledge that there are no guarantees or assurances made with respect to the results of taking metformin prescribed for you, and there are no guarantees that there will not be side effects and complications.

COMPLETE MEDICAL HISTORY: You understand that metformin may be inappropriate and unsafe if you have certain health conditions, allergies, or take certain medications or supplements, whether prescribed or over-the-counter. For this and other reasons, you understand that it is vital that you truthfully and accurately disclose all health information requested by your prescribing Healthcare Provider including allergies, medications you are taking (both prescription and over the counter), medical/surgical/social/family history, and pertinent lab results, and keep your Medical Group prescribing Healthcare Provider updated as to any changes in your health conditions and history during treatment with metformin, and you agree there shall be no liability on the part of the Medical Groups, the Healthcare Providers or Superpower if you fail to do so.

CERTIFICATION OF CONSENT TO PROCEED WITH TREATMENT: BY CLICKING "I AGREE" OR OTHERWISE INDICATING YOUR ACCEPTANCE, YOU ARE PROVIDING YOUR INFORMED CONSENT TO RECEIVE METFORMIN THROUGH THIS SERVICE. YOU CERTIFY THAT YOU ARE NOT CONSENTING ON BEHALF OF AMINOR CHILD, AS THIS SERVICE DOES NOT PROVIDE TREATMENT TO INDIVIDUALS UNDER THE AGE OF 18.

I confirm and agree that: I have read this entire Informed Consent, and I understand and agree to the information herein. I understand this is an elective treatment. The nature of the therapy, and the potential risks, benefits and alternatives have been explained to me, and I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction. I hereby freely and voluntarily accept all risks associated with metformin and elect and consent to proceed with treatment.

 

MEMBERNAME:___________________________

SIGNATURE:_____________________________

DATE:__________________________________

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