PATIENT INFORMED CONSENT FOR PEPTIDE THERAPY

This document explains peptide therapy, including its investigational status, benefits, risks, and alternatives. Please

read carefully and ask questions before signing.

1. DESCRIPTION OF PEPTIDE THERAPY

Peptides are short chains of amino acids that may be

prescribed or recommended by healthcare providers for

wellness, metabolic, aesthetic, or functional purposes.

Therapy may involve subcutaneous injections or other

routes as determined by your provider.

2. FDA STATUS DISCLOSURE

Many peptides used in clinical practice are NOT approved

by the U.S. FDA for the intended use prescribed. These

may be compounded and prescribed based on clinical

judgment and off-label use. The FDA has not evaluated

these peptides for safety or effectiveness for your specific

condition. Compounded medications, if used, are

prepared by licensed compounding pharmacies and are

not FDA-approved.

3. POTENTIAL BENEFITS

Potential benefits may include support of metabolic

function, appetite regulation, tissue repair and recovery,

body composition support, skin or hair health, sexual

health support, and overall wellness. Individual results

vary and no guarantees are made.

4. RISKS AND SIDE EFFECTS

Known and unknown risks may include injection-site

reactions, nausea, gastrointestinal symptoms, fatigue,

headaches, allergic reactions, changes in blood sugar,

hormonal changes, fluid retention, numbness/tingling, or

other unforeseen effects. Long-term risks may not be fully

known.

5. HORMONAL / IGF-1 AND CANCER RISK DISCLOSURE

Certain peptide therapies may influence growth hormone

(GH) and insulin-like growth factor-1 (IGF-1), which can

affect cellular growth. These effects may theoretically

influence growth of existing abnormal or cancerous cells.

Patients with personal or significant family history of

cancer, including hormone-sensitive cancers (e.g., breast

cancer), should discuss risks with their provider.

6. MONITORING REQUIREMENTS

Periodic laboratory monitoring may be required, including

glucose, HbA1c, IGF-1, lipid profile, or other tests as

indicated. You agree to comply with monitoring and

follow-up.

7. ALTERNATIVES

Alternatives include FDA-approved medications, lifestyle

modifications, diet and exercise, or no treatment.

8. VOLUNTARY PARTICIPATION

Participation is voluntary and you may discontinue at any

time without affecting access to care.

9. NO GUARANTEE OF RESULTS

No guarantees or assurances are made regarding

effectiveness or results.

10. PATIENT RESPONSIBILITIES

Follow instructions, report side effects, disclose medical

history, and update your provider with any changes.

11. TELEHEALTH DISCLOSURE

Telehealth services, if used, comply with applicable state

laws and may require identity verification and audio-visual

consultation.

12. ACKNOWLEDGMENT AND CONSENT

By signing, you acknowledge understanding of this

document, opportunity to ask questions, and voluntary

consent to receive therapy.

Clear