CONSENT FORM FOR PEPTIDE THERAPY

Introduction

Peptide therapy involves the use of specific peptides—short chains of amino acids—that are designed to stimulate natural biological processes within the body. Peptides can influence various functions such as hormone production, immune response, tissue repair, and metabolism. Peptide therapy is considered a relatively new field and may be used for purposes including but not limited to anti-aging, muscle growth, fat loss, improved recovery, enhanced cognitive function, and immune support. Some of these peptides can be considered research and/or cosmetic in nature and may not be FDA approved.

Purpose of Treatment & Potential Benefits

The goal of peptide therapy is to support and optimize your body’s natural functions. The specific peptide(s) recommended for you is intended to address some or all of the following concerns:

• Muscle Recovery & Growth

• Improved Sleep & Mood

• Weight Loss & Management

• Increased Energy & Performance

• Hormone Regulation

• Sexual Arousal / Desire / Satisfaction

• Body Composition

• Sleep Quality

• Growth Hormone Secretion

• Anti-aging and/or Skin health

• Immune System Support

• Metabolic Health

• Neurological Health - Cognitive Function

• Fertility

• Insulin Sensitivity

• Mood

• Gut Health

• Tissue Regeneration

• Bone Health

Potential Risks and Side Effects

While peptide therapy is generally well-tolerated, potential side effects may include:

• No guarantee of effectiveness for any medical or performance enhancing purpose.

• The long-term safety of peptides in humans is unknown.

• Possible theoretical risks include interactions with other medications, stimulation of other body functions, and potential side effects on the immune system or underlying cancers.

• Injection site reactions (redness, swelling, bruising, bleeding).

• An infection from an injection is possible. Due to many factors, mild to severe infections are possible.

• Nausea, gastrointestinal discomfort and/or vomiting.

• Fatigue or dizziness including possible fever.

• Hormonal imbalances.

• Itching, Headaches, Flushing and other Allergic reactions (rare), including life threatening allergies.

• Additional side effects not listed may also occur.

Alternative Treatments

I understand that alternative treatments including doing nothing, standard medication use, surgery or other therapeutic intervention, hormone replacement therapy, dietary changes, exercise programs, and other medical interventions, are available.

Consent and Acknowledgment

I have been informed of the nature of peptide therapy, including its potential benefits, risks, and alternatives. I have had the opportunity to ask questions, and my questions have been answered to my satisfaction. I understand that peptide therapy is not guaranteed to achieve the intended results, and that ongoing monitoring may be required. I agree to follow the treatment plan as prescribed and to inform my healthcare provider of any side effects or changes in my health.

Having read this, I hereby acknowledge that I am voluntarily undergoing peptide therapy and that I hereby relieve the medical provider, staff and medical management company of any legal responsibility regarding side effects or complications that may occur due to receiving peptide therapies. I certify that if any concerns or side effects occur, I will promptly notify the provider’s medical office. I also understand that my provider, staff and medical management company are not responsible for any manufacturing issues related to these peptides, such as sterility and potency, which are the sole responsibility of the peptide supplier. I certify that I understand all the above information and that I have no questions about this.

I voluntarily consent to receive peptide therapy and understand that I may withdraw my consent at any time without penalty or loss of future care.

By agreeing, I also certify I am not pregnant nor am I aware of any active forms of cancer.