PEPTIDE THERAPY CONSENT FORM 

PEPTIDE THERAPY INFORMED CONSENT


WHAT IS PEPTIDE THERAPY?

Peptide therapy uses specific amino acid sequences to support various functions in your body. At Optimal You LLC, we offer:
SERMORELIN:
  • Stimulates natural growth hormone production
  • May improve: sleep quality, recovery, lean muscle, fat loss, skin elasticity, overall vitality
NAD+ (Nicotinamide Adenine Dinucleotide):
  • Essential for cellular energy production
  • May improve: mental clarity, energy levels, metabolic function, cellular repair, healthy aging
COMBINATION THERAPY:
  • Sermorelin + NAD+ used together for enhanced benefits

OFF-LABEL USE

I understand that peptide therapies may be prescribed for "off-label" uses (not FDA-approved for my specific condition). My provider has explained the potential benefits and risks, and I consent to this treatment

POTENTIAL BENEFITS

While results vary, potential benefits may include:
  • Improved energy and vitality
  • Better sleep quality
  • Enhanced recovery and healing
  • Increased lean muscle mass
  • Reduction in body fat
  • Improved skin appearance
  • Enhanced mental clarity
  • Support for healthy aging
  • Optimized metabolic function
I understand results are not guaranteed and vary by individual.

POTENTIAL SIDE EFFECTS

SERMORELIN may cause:
  • Injection site reactions (redness, swelling, pain)
  • Headache
  • Flushing
  • Dizziness
  • Nausea
  • Hyperactivity
NAD+ may cause:
  • Injection site discomfort
  • Nausea
  • Cramping
  • Flushing
  • Headache
  • Temporary fatigue
I agree to report any concerning symptoms immediately.

CONTRAINDICATIONS

Peptide therapy may not be appropriate if you have:
  • Active cancer or history of cancer
  • Pituitary or brain tumor
  • Pregnancy or breastfeeding
  • Severe uncontrolled diabetes
  • Severe kidney or liver disease
  • Allergy to peptides or injection ingredients
I have disclosed my complete medical history including current medications, supplements, and health conditions.

ADMINISTRATION

  • Peptides are given via subcutaneous injection (under the skin)
  • I will receive proper instruction on self-administration
  • I understand the importance of following the prescribed protocol
  • Peptides must be stored in refrigerator
  • I will dispose of needles safely

PREGNANCY WARNING

I understand peptide therapy is NOT recommended during pregnancy or breastfeeding. If I am of childbearing age, I will use appropriate contraception and notify my provider immediately if I become pregnant.

FINANCIAL RESPONSIBILITY

I understand:
  • Peptide therapy may not be covered by insurance
  • I am responsible for all treatment costs
  • Payment is due at time of service unless other arrangements are made

PATIENT RESPONSIBILITIES

I agree to:
  • Follow the prescribed treatment protocol
  • Report any side effects or concerns promptly
  • Attend scheduled follow-up appointments
  • Store and handle peptides properly
  • Not share my prescribed peptides with others
  • Dispose of needles safely

MONITORING & FOLLOW-UP

I understand that follow-up appointments and/or lab work may be necessary to monitor my progress and safety. I agree to complete recommended monitoring as advised.

RIGHT TO REFUSE

I understand:
  • I have the right to refuse treatment at any time
  • I may discontinue treatment at any time
  • My provider may discontinue treatment if deemed medically necessary

I ACKNOWLEDGE THAT I HAVE RECEIVED A COPY AND UNDERSTAND THE INSTRUCTIONS ON THIS FORM.

By checking this box, I agree to use electronic records and signatures and I acknowledge that I have read the related consumer disclosure.
 I am the parent/guardian of this patient
I acknowledge that: