Informed Consent for Peptide Therapy
Please initial each point acknowledging you have read and understand each one:
Peptides are amino acids that have biological activity which mimic certain hormones within the body. Peptides have the ability of increasing certain naturally producing hormones within the body to illicit a certain effect which will be discussed by Casey Elkins, DNP, APRN/ Restoration Health and Wellness, LLC. Certain peptides are FDA approved for the treatment of various diseases while other peptides are investigational new drugs that are not FDA approved to be marketed for consumption for humans even though clinical trials have shown them to have a favorable safety profile
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Peptide therapy for the purpose of preventative care, weight loss, performance enhancement, anti-aging, and any additional condition discussed by Casey Elkins, DNP, APRN/ Restoration Health and Wellness, LLC is considered by the FDA to be “off-label use.”
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Peptide therapy can be administered either orally, subcutaneously, intramuscularly, intravenously, or intranasally. The various preparations will be discussed with me by Casey Elkins, DNP, APRN/ Restoration Health and Wellness, LLC
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Peptide therapies being administered by Casey Elkins, DNP, APRN/ Restoration Health and Wellness, LLC are prepared by registered compounding pharmacies that comply with all state and federal regulations.
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I acknowledge that Casey Elkins, DNP, APRN/ Restoration Health and Wellness, LLC is not responsible for any manufacturing issues related to peptides prepared by compounding pharmacies and that the sole responsibility for sterility, potency, and safety lie with these pharmacies.
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I understand that peptide therapies are not necessarily approved for my medical conditions and they are not a medical necessity, rather, they are an adjunctive and complimentary therapy to my treatment plan. Therefore, I acknowledge that it is an elective treatment option.
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(WOMEN ONLY) There has been little research regarding the safety of peptide therapy in pregnant and breast-feeding women. I certify that I am not pregnant nor plan on becoming pregnant while on peptide therapy.
I understand that with any drug, peptide therapies can carry potential side effects, including but not limited to: Rash, fever, nausea, vomiting, allergic reactions, decreased insulin sensitivity, flushing, headache, fatigue, lightheadedness, abdominal cramping, joint pain, fluid retention, and additional side effects not listed that will be discussed during your evaluation with Casey Elkins, DNP, APRN/ Restoration Health and Wellness, LLC
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I understand that alternatives to peptide therapy are: Doing nothing, FDA approved standard medication treatments, Referral to specialists, Surgery
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I acknowledge that there are no guarantees relating to the efficacy of peptide therapies and that Casey Elkins, DNP, APRN/ Restoration Health and Wellness, LLC are not responsible for my individual performance/results and ability to also exercise and diet. Further, I agree that I understand that Restoration Health and Wellness, LLC does not offer refunds if specific results are not attained.
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I certify that I will notify Casey Elkins, DNP, APRN/ Restoration Health and Wellness, LLC immediately if I have any concerns or side effects.
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I certify that I have had the risks and benefits discussed with me about peptide therapy and that I have had all my questions and concerns answered to my satisfaction by Casey Elkins, DNP, APRN/ Restoration Health and Wellness, LLC
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I hereby voluntarily consent to be evaluated and treated by Casey Elkins, DNP, APRN/ Restoration Health and Wellness, LLC with the goal of improving my health, performance, and possibly delaying the effects of aging through peptide therapies.
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